MEDICARE: LUXE MEDICAL WIGS 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	332BC3200X	Customized Equipment (DME)
2	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1750241824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUXE MEDICAL WIGS LLC

Provider Business Mailing Address
First Line	:	1309 ASHLAND DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-8414
Country	:	US
Telephone Number	:	470-606-6050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1609 BLUE RIDGE TER
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-1711
Country	:	US
Telephone Number	:	470-606-6050
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CRANIAL PROTHESIS SPECIALIST
Name	:	DEMAZADA GARY
Credential	:
Telephone Number	:	470-606-6050

Provider Enumeration Date	:	11/12/2025
Last Update Date	:	04/06/2026

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