Provider Demographics
NPI:1619737236
Name:JENNYS WIG CENTER
Entity Type:Organization
Organization Name:JENNYS WIG CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-RUDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-771-3883
Mailing Address - Street 1:384 S TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2502
Mailing Address - Country:US
Mailing Address - Phone:714-771-3883
Mailing Address - Fax:
Practice Address - Street 1:384 S TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2502
Practice Address - Country:US
Practice Address - Phone:714-771-3883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty