Healthcare Provider Details

I. General information

NPI: 1174827398
Provider Name (Legal Business Name): KELLY ROBERTS WIGGEN COF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 EAST WALKER STREET
EAST FLAT ROCK NC
28726
US

IV. Provider business mailing address

107 EAST WALKER STREET
EAST FLAT ROCK NC
28726
US

V. Phone/Fax

Practice location:
  • Phone: 828-595-9371
  • Fax: 828-595-9373
Mailing address:
  • Phone: 828-595-9371
  • Fax: 828-595-9373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: