MEDICARE: PINK RIBBON MASTECTOMY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies		MN
2	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1134110802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINK RIBBON MASTECTOMY, INC.

Provider Business Mailing Address
First Line	:	101 GRAYSTONE PLZ
Second Line	:	SUITE 200
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3043
Country	:	US
Telephone Number	:	218-846-1800
Fax Number	:	218-846-1803

Provider Business Practice Location Address
First Line	:	101 GRAYSTONE PLZ
Second Line	:	SUITE 200
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3043
Country	:	US
Telephone Number	:	218-846-1800
Fax Number	:	218-846-1803

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MS. DAWN RENEE' HEIDE-MCDOUGALL
Credential	:	RFM
Telephone Number	:	218-846-1800

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	09/11/2025

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