Provider Demographics
NPI:1194343103
Name:SERENITY WIG DESIGN LLC
Entity type:Organization
Organization Name:SERENITY WIG DESIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-668-8336
Mailing Address - Street 1:65 PITCAIRN DR
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-1019
Mailing Address - Country:US
Mailing Address - Phone:973-668-8336
Mailing Address - Fax:
Practice Address - Street 1:461 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1954
Practice Address - Country:US
Practice Address - Phone:973-668-8336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier