Organization
WIG WAM BOUTIQUE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARSHALENE EVANS (MEMBER & REGISTERED AGENT)
(812) 498-1857
Entity
Organization
Contact information
Practice address
313 W 17TH ST, BLOOMINGTON, IN 47404-3453
(812) 332-4914
Mailing address
397 S GUM ST, NORTH VERNON, IN 47265-2055
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Enumeration date
12/15/2017
Last updated
12/15/2017
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