Healthcare Provider Details

I. General information

NPI: 1568049138
Provider Name (Legal Business Name): THE LONDON KNOT WIG BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6957 AQUAMARINE CT
CAPITOL HEIGHTS MD
20743-1879
US

IV. Provider business mailing address

6957 AQUAMARINE CT
CAPITOL HEIGHTS MD
20743-1879
US

V. Phone/Fax

Practice location:
  • Phone: 301-792-4607
  • Fax:
Mailing address:
  • Phone: 301-792-4607
  • 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 Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: KIERRA LASHAE ROYSTER
Title or Position: ADMIN DIRECTOR
Credential:
Phone: 301-792-4607