Provider Demographics
NPI:1518155670
Name:ANTOINETTE'S WIGS & DAISY BOUTIQUE MASTECTOMY APPEARL
Entity Type:Organization
Organization Name:ANTOINETTE'S WIGS & DAISY BOUTIQUE MASTECTOMY APPEARL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CERTIFIED FITTER
Authorized Official - Prefix:MISS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-385-5736
Mailing Address - Street 1:4714 147TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2527
Mailing Address - Country:US
Mailing Address - Phone:708-385-5736
Mailing Address - Fax:708-385-5754
Practice Address - Street 1:4714 147TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-2527
Practice Address - Country:US
Practice Address - Phone:708-385-5736
Practice Address - Fax:708-385-5754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-13
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL31674331335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4313710001Medicare PIN