Healthcare Provider Details

I. General information

NPI: 1891940201
Provider Name (Legal Business Name): CINDERELLA WIGS & BREAST PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 11/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LAKE DR
TIPTONVILLE TN
38079-1247
US

IV. Provider business mailing address

140 LAKE DR.
TIPTONVILLE TN
38079-1359
US

V. Phone/Fax

Practice location:
  • Phone: 731-623-4333
  • Fax: 731-623-4333
Mailing address:
  • Phone: 731-623-4333
  • Fax: 731-623-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateTN

VIII. Authorized Official

Name: NORMAJEAN JOHNSON
Title or Position: OWNER
Credential: ABC / BOC
Phone: 731-623-4333