Provider Demographics
NPI:1285461798
Name:PRODIGY HANDS CUSTOM WIGS BY QUAY
Entity type:Organization
Organization Name:PRODIGY HANDS CUSTOM WIGS BY QUAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAQUILA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-508-2950
Mailing Address - Street 1:9324 WHITCOMB ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2218
Mailing Address - Country:US
Mailing Address - Phone:124-850-8950
Mailing Address - Fax:
Practice Address - Street 1:9324 WHITCOMB ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-2218
Practice Address - Country:US
Practice Address - Phone:124-850-8950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies