MEDICARE: HOUSE OF Q RIGGS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	CL1220368	FL

General Provider Information

NPI Number	:	1598110025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSE OF Q RIGGS LLC

Provider Business Mailing Address
First Line	:	2917 NE 16TH TER
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32609-3234
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 NE 1ST ST
Second Line	:	SUITE 117
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-5311
Country	:	US
Telephone Number	:	352-575-7032
Fax Number	:

Authorized Official
Title or Position	:	NON-SURGICAL HAIR REPLACEMENT
Name	:	MRS. MARQUITA RIGGINS
Credential	:
Telephone Number	:	352-575-7032

Provider Enumeration Date	:	05/03/2016
Last Update Date	:	06/02/2016

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