Provider Demographics
NPI:1760637599
Name:BRANDIS WIG SALON
Entity Type:Organization
Organization Name:BRANDIS WIG SALON
Other - Org Name:BRANDIS HAIR COMPANY DBA BRANDIS WIG SALON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-771-7355
Mailing Address - Street 1:7275 103RD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210
Mailing Address - Country:US
Mailing Address - Phone:904-771-7355
Mailing Address - Fax:904-772-8316
Practice Address - Street 1:7275 103RD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-771-7355
Practice Address - Fax:904-772-8316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier