Provider Demographics
NPI:1265867253
Name:CYNTHIA'S WIG BOUTIQUE LLC
Entity Type:Organization
Organization Name:CYNTHIA'S WIG BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:850-386-9447
Mailing Address - Street 1:1641 MAHAN CENTER BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7404
Mailing Address - Country:US
Mailing Address - Phone:850-386-9447
Mailing Address - Fax:
Practice Address - Street 1:1641 MAHAN CENTER BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7404
Practice Address - Country:US
Practice Address - Phone:850-386-9447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies