Provider Demographics
NPI:1053549402
Name:CROWNING GLORY LACE WIGS
Entity type:Organization
Organization Name:CROWNING GLORY LACE WIGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-671-0516
Mailing Address - Street 1:8100 S STONY ISLAND AVE
Mailing Address - Street 2:UNIT F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1734
Mailing Address - Country:US
Mailing Address - Phone:773-356-9447
Mailing Address - Fax:773-356-9447
Practice Address - Street 1:8100 S STONY ISLAND AVE
Practice Address - Street 2:UNIT F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1734
Practice Address - Country:US
Practice Address - Phone:773-356-9447
Practice Address - Fax:773-356-9447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment