MEDICARE: MEDICAL WIG BOUTIQUE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1295694958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL WIG BOUTIQUE, LLC

Provider Business Mailing Address
First Line	:	12514 MILL CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070
Country	:	US
Telephone Number	:
Fax Number	:	713-715-9448

Provider Business Practice Location Address
First Line	:	12514 MILL CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4912
Country	:	US
Telephone Number	:	713-715-9448
Fax Number	:	713-715-9448

Authorized Official
Title or Position	:	CRANIAL PROTHESIS SPECIALIST
Name	:	ASHLEY HALL
Credential	:
Telephone Number	:	713-715-9448

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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Directions to “MEDICAL WIG BOUTIQUE, LLC ” Practice Location

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