Provider Demographics
NPI:1760362198
Name:ENVISIONING CROWN WIGS CRANIAL PROSTHESIS SPECIALIST LLC
Entity type:Organization
Organization Name:ENVISIONING CROWN WIGS CRANIAL PROSTHESIS SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:CPS
Authorized Official - Phone:815-386-6568
Mailing Address - Street 1:475 BROWN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2325
Mailing Address - Country:US
Mailing Address - Phone:815-937-7962
Mailing Address - Fax:815-936-8650
Practice Address - Street 1:475 BROWN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2325
Practice Address - Country:US
Practice Address - Phone:815-937-7962
Practice Address - Fax:815-936-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty