Provider Demographics
NPI:1275264020
Name:PRISTINE WIGS
Entity Type:Organization
Organization Name:PRISTINE WIGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL WIG SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-281-0496
Mailing Address - Street 1:15306 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3439
Mailing Address - Country:US
Mailing Address - Phone:347-281-0496
Mailing Address - Fax:
Practice Address - Street 1:15306 78TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3439
Practice Address - Country:US
Practice Address - Phone:347-281-0496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier