Healthcare Provider Details

I. General information

NPI: 1619737236
Provider Name (Legal Business Name): JENNYS WIG CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 S TUSTIN ST
ORANGE CA
92866-2502
US

IV. Provider business mailing address

384 S TUSTIN ST
ORANGE CA
92866-2502
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-3883
  • Fax:
Mailing address:
  • Phone: 714-771-3883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: BRISSA GARCIA-RUDDY
Title or Position: OWNER
Credential:
Phone: 714-771-3883