Healthcare Provider Details

I. General information

NPI: 1295367050
Provider Name (Legal Business Name): SOCIAL WIG CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 ALTA WAY
CORTE MADERA CA
94925-1501
US

IV. Provider business mailing address

39 ALTA WAY
CORTE MADERA CA
94925-1501
US

V. Phone/Fax

Practice location:
  • Phone: 415-849-5378
  • Fax:
Mailing address:
  • Phone: 415-849-5378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ALLISON OMBRES
Title or Position: OWNER
Credential:
Phone: 415-849-5378