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General NPI Number Information
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NPI Number | 1275264020
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Entity Type | Organization
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Legal Business Name | PRISTINE WIGS
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Dates
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Enumeration Date | 06/22/2022
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Last Update Date | 06/22/2022
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Provider Practice Location Address
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Address Line | 15306 78TH AVE
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City | FLUSHING
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State | NY
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Zip | 11367-3439
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Country | US
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Telephone | 347-281-0496
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Fax |
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Provider Business Mailing Address
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Address Line | 15306 78TH AVE
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City | FLUSHING
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State | NY
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Zip | 11367-3439
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Country | US
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Telephone | 347-281-0496
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Fax |
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Authorized Official
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Title or Position | MEDICAL WIG SPECIALIST
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Name | DIANA YAKUBOVA
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Credential |
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Telephone | 347-281-0496
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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