Provider Demographics
NPI:1447499116
Name:THE WIG DOCTOR
Entity type:Organization
Organization Name:THE WIG DOCTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:DEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-622-8328
Mailing Address - Street 1:115 GLACIER LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-1364
Mailing Address - Country:US
Mailing Address - Phone:214-622-8328
Mailing Address - Fax:972-291-8002
Practice Address - Street 1:115 GLACIER LN
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-1364
Practice Address - Country:US
Practice Address - Phone:214-622-8328
Practice Address - Fax:972-291-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier