Provider Demographics
NPI:1457645566
Name:KB WIGS & BEAUTY SUPPLY
Entity Type:Organization
Organization Name:KB WIGS & BEAUTY SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:TONY
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-686-0653
Mailing Address - Street 1:317 INDUSTRIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2901
Mailing Address - Country:US
Mailing Address - Phone:734-697-6327
Mailing Address - Fax:734-697-9177
Practice Address - Street 1:317 INDUSTRIAL PARK DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2901
Practice Address - Country:US
Practice Address - Phone:734-697-6327
Practice Address - Fax:734-697-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI335E00000X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier