=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689413718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROWN ME WIGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2024
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 W 6TH ST STE 113
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-377-9201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2828 N CENTRAL AVE # 1021
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85004-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-377-9201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAAGER
-----------------------------------------------------
Name | MRS. LESLIE WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-377-9201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------