Provider Demographics
NPI:1558931691
Name:COEUR D'ALENE WIGS LLC
Entity Type:Organization
Organization Name:COEUR D'ALENE WIGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LINDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-551-2761
Mailing Address - Street 1:PO BOX 1073
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1073
Mailing Address - Country:US
Mailing Address - Phone:208-651-5109
Mailing Address - Fax:
Practice Address - Street 1:296 W SUNSET AVE STE 17
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8367
Practice Address - Country:US
Practice Address - Phone:208-551-2761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty