MEDICARE: DIAMOND LACED MEDICAL WIGS

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1487277323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAMOND LACED MEDICAL WIGS

Provider Business Mailing Address
First Line	:	1131 CEDAR AVE # 1
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45224-2615
Country	:	US
Telephone Number	:	513-909-4843
Fax Number	:

Provider Business Practice Location Address
First Line	:	1131 CEDAR AVE # 1
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45224-2615
Country	:	US
Telephone Number	:	513-909-4843
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAUNA HARRINGTON
Credential	:
Telephone Number	:	513-909-4843

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	04/28/2021

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Directions to “DIAMOND LACED MEDICAL WIGS ” Practice Location

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