Provider Demographics
NPI:1518640705
Name:MARY'S MAJESTIC MEDICAL WIGS
Entity Type:Organization
Organization Name:MARY'S MAJESTIC MEDICAL WIGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROSTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-603-1761
Mailing Address - Street 1:3155 COLUMBIA BLVD # 1035
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7820
Mailing Address - Country:US
Mailing Address - Phone:321-603-1761
Mailing Address - Fax:321-603-1761
Practice Address - Street 1:2589 WILEY AVE
Practice Address - Street 2:
Practice Address - City:MIMS
Practice Address - State:FL
Practice Address - Zip Code:32754-4506
Practice Address - Country:US
Practice Address - Phone:321-603-1761
Practice Address - Fax:321-603-1761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier