Provider Demographics
NPI:1376939462
Name:YONGS WIG SALON,INC
Entity Type:Organization
Organization Name:YONGS WIG SALON,INC
Other - Org Name:YONGS MASTECTOMY PRODUCTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YONG
Authorized Official - Middle Name:S
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-638-8832
Mailing Address - Street 1:1834 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2822
Mailing Address - Country:US
Mailing Address - Phone:321-638-8832
Mailing Address - Fax:321-631-8022
Practice Address - Street 1:1834 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2822
Practice Address - Country:US
Practice Address - Phone:321-638-8832
Practice Address - Fax:321-631-8022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YONGS WIG SALON ,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-15
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1580119145924171W00000X, 335E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty