MEDICARE: BUILD-A-WIG

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1841978376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUILD-A-WIG

Provider Business Mailing Address
First Line	:	9442 COUNTRY LAKE DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70817-7027
Country	:	US
Telephone Number	:	225-223-8053
Fax Number	:

Provider Business Practice Location Address
First Line	:	149 CORA DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70815-4202
Country	:	US
Telephone Number	:	225-223-8053
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JERICA LAFAYETTE
Credential	:
Telephone Number	:	225-223-8053

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	07/05/2023

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Directions to “BUILD-A-WIG ” Practice Location

Language	Start Address	Practice Location

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