Healthcare Provider Details

I. General information

NPI: 1558931691
Provider Name (Legal Business Name): COEUR D'ALENE WIGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 W SUNSET AVE STE 17
COEUR D ALENE ID
83815-8367
US

IV. Provider business mailing address

PO BOX 1073
HAYDEN ID
83835-1073
US

V. Phone/Fax

Practice location:
  • Phone: 208-551-2761
  • Fax:
Mailing address:
  • Phone: 208-651-5109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER LYNN LINDLEY
Title or Position: OWNER/PARTNER
Credential:
Phone: 208-551-2761