Provider Demographics
NPI:1871754341
Name:THE WIG SHOPPE
Entity type:Organization
Organization Name:THE WIG SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDYCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-412-8810
Mailing Address - Street 1:9960 LINN STATION RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223
Mailing Address - Country:US
Mailing Address - Phone:502-412-8810
Mailing Address - Fax:502-394-0783
Practice Address - Street 1:9960 LINN STATION RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223
Practice Address - Country:US
Practice Address - Phone:502-412-8810
Practice Address - Fax:502-394-0783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246536229N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Single Specialty