Provider Demographics
NPI:1871817916
Name:FASHION WIG SHOP & GIFTS LLC
Entity type:Organization
Organization Name:FASHION WIG SHOP & GIFTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCELVEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-774-0139
Mailing Address - Street 1:540 BULTMAN DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2592
Mailing Address - Country:US
Mailing Address - Phone:803-774-0139
Mailing Address - Fax:803-774-0139
Practice Address - Street 1:540 BULTMAN DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2592
Practice Address - Country:US
Practice Address - Phone:803-774-0139
Practice Address - Fax:803-774-0139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20537335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier