Provider Demographics
NPI:1326886375
Name:THE CLASSIC WIG BAR
Entity type:Organization
Organization Name:THE CLASSIC WIG BAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-703-6679
Mailing Address - Street 1:15331 W BELL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4102
Mailing Address - Country:US
Mailing Address - Phone:623-257-6655
Mailing Address - Fax:
Practice Address - Street 1:20250 N 67TH AVE APT 2107
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6640
Practice Address - Country:US
Practice Address - Phone:205-703-6679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty