Provider Demographics
NPI:1427873975
Name:MEDICAL WIG LLC
Entity type:Organization
Organization Name:MEDICAL WIG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CRANIAL PROSTHESIS
Authorized Official - Phone:800-342-9913
Mailing Address - Street 1:4301 S FLAMINGO RD STE 106
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-1902
Mailing Address - Country:US
Mailing Address - Phone:800-342-9913
Mailing Address - Fax:
Practice Address - Street 1:2424 W OAKLAND PARK BLVD STE 109
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1414
Practice Address - Country:US
Practice Address - Phone:800-342-9913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies