Provider Demographics
NPI:1386001907
Name:WIGGIES
Entity Type:Organization
Organization Name:WIGGIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEBELLO
Authorized Official - Suffix:
Authorized Official - Credentials:CRANIAL PROSTHETICS
Authorized Official - Phone:845-430-0944
Mailing Address - Street 1:26 ELM RD
Mailing Address - Street 2:
Mailing Address - City:LK PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10537-1416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 ELM RD
Practice Address - Street 2:
Practice Address - City:LK PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10537-1416
Practice Address - Country:US
Practice Address - Phone:845-430-0944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22M00051696335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY22M00051696OtherDIVISION OF LICENSING SERVICES