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General NPI Number Information
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NPI Number | 1598192429
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Entity Type | Organization
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Legal Business Name | THE WIG OUTLET
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Dates
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Enumeration Date | 10/10/2013
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Last Update Date | 10/10/2013
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Provider Practice Location Address
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Address Line | 194 CENTRAL PARK AVENUE
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City | HARTSDALE
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State | NY
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Zip | 10530
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Country | US
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Telephone | 914-644-9447
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Fax |
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Provider Business Mailing Address
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Address Line | 194 SO. CENTRAL PARK AVENUE
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City | HARTSDALE
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State | NY
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Zip | 10530
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Country | US
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Telephone | 914-644-9447
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | MS. ERICA CHRISTIN BRODERICK
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Credential |
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Telephone | 914-644-9447
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | NY
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