Provider Demographics
NPI:1841927654
Name:MANIFEST WIGS LLC
Entity type:Organization
Organization Name:MANIFEST WIGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BREANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:832-800-4392
Mailing Address - Street 1:6022 E SAM HOUSTON PKWY N # 1052
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77049-2511
Mailing Address - Country:US
Mailing Address - Phone:832-800-4392
Mailing Address - Fax:832-218-5555
Practice Address - Street 1:6464 E SAM HOUSTON PKWY N APT 410
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77049-7269
Practice Address - Country:US
Practice Address - Phone:832-800-4392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier