Healthcare Provider Details

I. General information

NPI: 1093520835
Provider Name (Legal Business Name): SHONDA WIGS REFINING BOUTIQUE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 10TH ST
LAKE CHARLES LA
70601-6537
US

IV. Provider business mailing address

2105 10TH ST
LAKE CHARLES LA
70601-6537
US

V. Phone/Fax

Practice location:
  • Phone: 337-244-2933
  • Fax:
Mailing address:
  • Phone: 337-244-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHONDA RENEE GOBERT
Title or Position: OWNER
Credential: COSMETOLOGIST
Phone: 337-244-2933