Provider Demographics
NPI:1770719536
Name:THE LACE WIG STORE AND SALON, LLC
Entity type:Organization
Organization Name:THE LACE WIG STORE AND SALON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:SINGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:CRANIAL PROSTHESIS
Authorized Official - Phone:251-300-8036
Mailing Address - Street 1:3202 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-4001
Mailing Address - Country:US
Mailing Address - Phone:251-300-8036
Mailing Address - Fax:
Practice Address - Street 1:3202 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-4001
Practice Address - Country:US
Practice Address - Phone:251-300-8036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL012455335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier