Provider Demographics
NPI:1891940201
Name:CINDERELLA WIGS & BREAST PROSTHETICS
Entity Type:Organization
Organization Name:CINDERELLA WIGS & BREAST PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NORMAJEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:ABC / BOC
Authorized Official - Phone:731-623-4333
Mailing Address - Street 1:140 LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079-1359
Mailing Address - Country:US
Mailing Address - Phone:731-623-4333
Mailing Address - Fax:731-623-4333
Practice Address - Street 1:140 LAKE DR
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079-1247
Practice Address - Country:US
Practice Address - Phone:731-623-4333
Practice Address - Fax:731-623-4333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455190OtherTENN CARE MEDICAID
TN4041082OtherBLUE CROSS BLUE SHIELD
TN4041082OtherBLUE CROSS BLUE SHIELD