Healthcare Provider Details

I. General information

NPI: 1306750021
Provider Name (Legal Business Name): MEDICAL WIG SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2056 E 3300 S
MILLCREEK UT
84109-2665
US

IV. Provider business mailing address

2056 E 3300 S
MILLCREEK UT
84109-2665
US

V. Phone/Fax

Practice location:
  • Phone: 385-202-4622
  • Fax:
Mailing address:
  • Phone: 661-714-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL

VIII. Authorized Official

Name: TENITA PARKER
Title or Position: OWNER
Credential:
Phone: 661-714-4665