Provider Demographics
NPI:1790016145
Name:PROSTHETIC WIG CENTER INC.
Entity Type:Organization
Organization Name:PROSTHETIC WIG CENTER INC.
Other - Org Name:PROSTHETIC WIG CENTER INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PROSTHETIC WIG CENTER INC.
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER,INSTRUCTOR,CE
Authorized Official - Phone:251-259-7233
Mailing Address - Street 1:2282 MOSS CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3783
Mailing Address - Country:US
Mailing Address - Phone:251-259-7233
Mailing Address - Fax:
Practice Address - Street 1:90 N SAGE AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-2638
Practice Address - Country:US
Practice Address - Phone:251-259-7233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL63085335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier