=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518011329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WENDY A. WIGMORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 04/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 480 REDWOOD ST STE 44
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-2958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-644-4170
-----------------------------------------------------
Fax | 707-644-4163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 480 REDWOOD ST STE 44
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-2958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-644-4170
-----------------------------------------------------
Fax | 707-644-4163
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WENDY ANN WIGMORE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 707-446-7014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PENDING
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------