Healthcare Provider Details

I. General information

NPI: 1194343103
Provider Name (Legal Business Name): SERENITY WIG DESIGN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 US HIGHWAY 46
FAIRFIELD NJ
07004-1954
US

IV. Provider business mailing address

65 PITCAIRN DR
ROSELAND NJ
07068-1019
US

V. Phone/Fax

Practice location:
  • Phone: 973-668-8336
  • Fax:
Mailing address:
  • Phone: 973-668-8336
  • 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: MRS. SUSAN LUPO
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 973-668-8336