Provider Demographics
NPI:1205375706
Name:D.D. DAUGHTERS LACE WIG BEAUTIQUE, LLC
Entity Type:Organization
Organization Name:D.D. DAUGHTERS LACE WIG BEAUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROSTHESIS SPECIALIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MYISHA
Authorized Official - Middle Name:DAKETA
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:COSMETOLOGIST
Authorized Official - Phone:267-453-9855
Mailing Address - Street 1:402 W TABOR RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:267-453-9855
Mailing Address - Fax:215-924-2763
Practice Address - Street 1:52 N YORK ROAD, SALON
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090
Practice Address - Country:US
Practice Address - Phone:215-346-2555
Practice Address - Fax:215-346-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225000000X
PACB121409335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty