Healthcare Provider Details

I. General information

NPI: 1649683145
Provider Name (Legal Business Name): T. ANDERSON WIGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5421 N 103RD ST SUITE 300
OMAHA NE
68134-1000
US

IV. Provider business mailing address

PO BOX 8735
OMAHA NE
68108-0735
US

V. Phone/Fax

Practice location:
  • Phone: 402-637-2475
  • Fax:
Mailing address:
  • Phone: 402-637-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License Number48699
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number48699
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number48699
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number48699
License Number StateNE

VIII. Authorized Official

Name: TAMEKA ANDERSON
Title or Position: COSMETOLOGIST
Credential:
Phone: 402-637-2475