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General NPI Number Information
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NPI Number | 1700104601
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Entity Type | Organization
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Legal Business Name | ELEGANCE LACE WIGS
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Dates
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Enumeration Date | 05/17/2010
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Last Update Date | 05/17/2010
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Provider Practice Location Address
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Address Line | 401 NC HIGHWAY 54 APT B3
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City | CARRBORO
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State | NC
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Zip | 27510-2103
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Country | US
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Telephone | 919-672-7912
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Fax | 772-673-7912
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Provider Business Mailing Address
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Address Line | PO BOX 10032
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City | CHAPEL HILL
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State | NC
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Zip | 27515-0032
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Country | US
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Telephone | 919-672-7912
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Fax | 772-673-7912
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Authorized Official
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Title or Position | OWNER
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Name | TIKISHA ROGERS
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Credential |
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Telephone | 919-672-7912
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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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