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General NPI Number Information
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NPI Number | 1821504697
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Entity Type | Organization
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Legal Business Name | WIG WAM BOUTIQUE LLC
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Dates
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Enumeration Date | 12/15/2017
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Last Update Date | 12/15/2017
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Provider Practice Location Address
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Address Line | 313 W 17TH ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-3453
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Country | US
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Telephone | 812-332-4914
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Fax |
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Provider Business Mailing Address
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Address Line | 397 S GUM ST
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City | NORTH VERNON
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State | IN
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Zip | 47265-2055
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER & REGISTERED AGENT
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Name | MARSHALENE EVANS
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Credential |
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Telephone | 812-498-1857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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