Provider Demographics
NPI:1518233477
Name:WIGS AND HAIR EXTENSIONS OF SARASOTA INC.
Entity Type:Organization
Organization Name:WIGS AND HAIR EXTENSIONS OF SARASOTA INC.
Other - Org Name:SARASOTA MASTECTOMY PRODUCTS.COM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLEVSON
Authorized Official - Suffix:
Authorized Official - Credentials:WIGS & BREAST FORMS
Authorized Official - Phone:941-600-6387
Mailing Address - Street 1:2412 STICKNEY POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231
Mailing Address - Country:US
Mailing Address - Phone:941-600-6387
Mailing Address - Fax:
Practice Address - Street 1:2412 STICKNEY POINT ROAD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-600-6387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL12258501744P3200X
FL400279332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty