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General NPI Number Information
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NPI Number | 1760637599
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Entity Type | Organization
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Legal Business Name | BRANDIS WIG SALON
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Dates
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Enumeration Date | 11/20/2008
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Last Update Date | 11/20/2008
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Provider Practice Location Address
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Address Line | 7275 103RD ST
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City | JACKSONVILLE
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State | FL
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Zip | 32210
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Country | US
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Telephone | 904-771-7355
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Fax | 904-772-8316
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Provider Business Mailing Address
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Address Line | 7275 103RD ST
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City | JACKSONVILLE
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State | FL
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Zip | 32210
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Country | US
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Telephone | 904-771-7355
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Fax | 904-772-8316
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MRS. BRENDA K CONNOR
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Credential |
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Telephone | 904-771-7355
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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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