Healthcare Provider Details

I. General information

NPI: 1902212855
Provider Name (Legal Business Name): LEGACY LACE WIGS LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 SAGEBRUSH DR SUITE 105
FLOWER MOUND TX
75028-2761
US

IV. Provider business mailing address

2201 LONG PRAIRIE RD 107-824
FLOWER MOUND TX
75022-4832
US

V. Phone/Fax

Practice location:
  • Phone: 972-914-9447
  • Fax:
Mailing address:
  • Phone: 972-914-9447
  • 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

VIII. Authorized Official

Name: RYAN SANFORD
Title or Position: COO
Credential:
Phone: 972-914-9447