Provider Demographics
NPI:1568049138
Name:THE LONDON KNOT WIG BOUTIQUE
Entity Type:Organization
Organization Name:THE LONDON KNOT WIG BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIERRA
Authorized Official - Middle Name:LASHAE
Authorized Official - Last Name:ROYSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-792-4607
Mailing Address - Street 1:6957 AQUAMARINE CT
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-1879
Mailing Address - Country:US
Mailing Address - Phone:301-792-4607
Mailing Address - Fax:
Practice Address - Street 1:6957 AQUAMARINE CT
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-1879
Practice Address - Country:US
Practice Address - Phone:301-792-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier