Provider Demographics
NPI:1750564472
Name:PREMIUM LACE FRONT WIGS
Entity type:Organization
Organization Name:PREMIUM LACE FRONT WIGS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-474-3187
Mailing Address - Street 1:3166 CHEROKEE ST NW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2883
Mailing Address - Country:US
Mailing Address - Phone:404-474-3187
Mailing Address - Fax:
Practice Address - Street 1:3166 CHEROKEE ST NW
Practice Address - Street 2:SUITE 102
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2883
Practice Address - Country:US
Practice Address - Phone:404-474-3187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment