Provider Demographics
NPI:1902212855
Name:LEGACY LACE WIGS LLC.
Entity Type:Organization
Organization Name:LEGACY LACE WIGS LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-914-9447
Mailing Address - Street 1:2201 LONG PRAIRIE RD
Mailing Address - Street 2:107-824
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4832
Mailing Address - Country:US
Mailing Address - Phone:972-914-9447
Mailing Address - Fax:
Practice Address - Street 1:2605 SAGEBRUSH DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2761
Practice Address - Country:US
Practice Address - Phone:972-914-9447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment