Healthcare Provider Details

I. General information

NPI: 1376939462
Provider Name (Legal Business Name): YONGS WIG SALON,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 US HIGHWAY 1
ROCKLEDGE FL
32955-2822
US

IV. Provider business mailing address

1834 US HIGHWAY 1
ROCKLEDGE FL
32955-2822
US

V. Phone/Fax

Practice location:
  • Phone: 321-638-8832
  • Fax: 321-631-8022
Mailing address:
  • Phone: 321-638-8832
  • Fax: 321-631-8022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number1580119145924
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number1580119145924
License Number StateFL

VIII. Authorized Official

Name: YONG S CORCORAN
Title or Position: PRESIDENT
Credential:
Phone: 321-638-8832