Healthcare Provider Details

I. General information

NPI: 1518233477
Provider Name (Legal Business Name): WIGS AND HAIR EXTENSIONS OF SARASOTA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 STICKNEY POINT ROAD
SARASOTA FL
34231
US

IV. Provider business mailing address

2412 STICKNEY POINT ROAD
SARASOTA FL
34231
US

V. Phone/Fax

Practice location:
  • Phone: 941-600-6387
  • Fax:
Mailing address:
  • Phone: 941-600-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCL1225850
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number400279
License Number StateFL

VIII. Authorized Official

Name: MS. NANCY J OLEVSON
Title or Position: PRESIDENT
Credential: WIGS & BREAST FORMS
Phone: 941-600-6387