=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013868652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTY'S WIG BOUTIQUE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2026
-----------------------------------------------------
Last Update Date | 02/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 JERSEY RIDGE RD
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52803-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-323-6231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 JERSEY RIDGE RD
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52803-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-650-6231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | KATHLEEN M GOODWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-323-6231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------