Provider Demographics
NPI:1649261249
Name:FIRM FOUNDATIONS SALON, INC.
Entity type:Organization
Organization Name:FIRM FOUNDATIONS SALON, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/FITTER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:606-834-1040
Mailing Address - Street 1:1566 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1676
Mailing Address - Country:US
Mailing Address - Phone:606-834-1040
Mailing Address - Fax:606-834-1044
Practice Address - Street 1:1566 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1676
Practice Address - Country:US
Practice Address - Phone:606-834-1040
Practice Address - Fax:606-834-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY149620335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5465520001Medicare ID - Type Unspecified