Provider Demographics
NPI:1679235303
Name:SALON ONE TWENTY FOUR L.L.C.
Entity type:Organization
Organization Name:SALON ONE TWENTY FOUR L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROSTHETIC SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAVON
Authorized Official - Middle Name:CHERALE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PROSTHETICSPECIALIST
Authorized Official - Phone:870-675-1246
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71711-0444
Mailing Address - Country:US
Mailing Address - Phone:870-454-7017
Mailing Address - Fax:
Practice Address - Street 1:124 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-4010
Practice Address - Country:US
Practice Address - Phone:870-454-7017
Practice Address - Fax:501-830-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies