Provider Demographics
NPI:1457949489
Name:THE WIG PHYSICIAN LLC
Entity Type:Organization
Organization Name:THE WIG PHYSICIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-406-9962
Mailing Address - Street 1:123 INSTITUTE ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-4908
Mailing Address - Country:US
Mailing Address - Phone:980-406-9962
Mailing Address - Fax:
Practice Address - Street 1:109 STONE RIDGE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-6300
Practice Address - Country:US
Practice Address - Phone:980-406-9962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier