Provider Demographics
NPI:1013362896
Name:A SPECIAL PLACE WIG BOUTIQUE, LLC
Entity Type:Organization
Organization Name:A SPECIAL PLACE WIG BOUTIQUE, LLC
Other - Org Name:A SPECIAL PLACE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HODGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-574-0100
Mailing Address - Street 1:5524 WILLIAMSON RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-1448
Mailing Address - Country:US
Mailing Address - Phone:540-265-2960
Mailing Address - Fax:540-265-2970
Practice Address - Street 1:5524 WILLIAMSON RD
Practice Address - Street 2:SUITE 6
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1448
Practice Address - Country:US
Practice Address - Phone:540-265-2960
Practice Address - Fax:540-265-2970
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A SPECIAL PLACE WIG GALLERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA100033237332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1629029848OtherSTATE OF NORTH CAROLINA