Healthcare Provider Details

I. General information

NPI: 1013362896
Provider Name (Legal Business Name): A SPECIAL PLACE WIG BOUTIQUE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 WILLIAMSON RD SUITE 6
ROANOKE VA
24012-1448
US

IV. Provider business mailing address

5524 WILLIAMSON RD SUITE 6
ROANOKE VA
24012-1448
US

V. Phone/Fax

Practice location:
  • Phone: 540-265-2960
  • Fax: 540-265-2970
Mailing address:
  • Phone: 540-265-2960
  • Fax: 540-265-2970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number100033237
License Number StateVA

VIII. Authorized Official

Name: MRS. JAMELA A HODGSON
Title or Position: OWNER
Credential:
Phone: 336-574-0100