Provider Demographics
NPI:1891193173
Name:WIGIT BOUTIQUE
Entity Type:Organization
Organization Name:WIGIT BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-864-9447
Mailing Address - Street 1:3214 HARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3902
Mailing Address - Country:US
Mailing Address - Phone:817-864-9447
Mailing Address - Fax:817-864-9997
Practice Address - Street 1:3214 HARWOOD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-3902
Practice Address - Country:US
Practice Address - Phone:817-864-9447
Practice Address - Fax:817-864-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment