Provider Demographics
NPI:1245230424
Name:WENDY WIGMORE
Entity type:Organization
Organization Name:WENDY WIGMORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIGMORE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-446-7014
Mailing Address - Street 1:506 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3912
Mailing Address - Country:US
Mailing Address - Phone:707-446-7014
Mailing Address - Fax:707-446-1871
Practice Address - Street 1:506 MAIN ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3912
Practice Address - Country:US
Practice Address - Phone:707-446-7014
Practice Address - Fax:707-446-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103834332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4241940001Medicare NSC