Provider Demographics
NPI:1528352556
Name:INCOGNITO WIGS NETWORK,LLC
Entity type:Organization
Organization Name:INCOGNITO WIGS NETWORK,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED COMOTOLOGIS
Authorized Official - Phone:573-760-0837
Mailing Address - Street 1:113 WEST LIBERTY STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1723
Mailing Address - Country:US
Mailing Address - Phone:573-760-0837
Mailing Address - Fax:
Practice Address - Street 1:103 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1723
Practice Address - Country:US
Practice Address - Phone:573-760-0837
Practice Address - Fax:573-760-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment