MEDICARE: PINK RIBBON REFLECTIONS, LLC

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

General Provider Information

NPI Number	:	1164594750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINK RIBBON REFLECTIONS, LLC

Provider Business Mailing Address
First Line	:	25 LINDSEY DR
Second Line	:
City	:	UNION
State	:	MO
Zip	:	63084-2087
Country	:	US
Telephone Number	:	636-583-4181
Fax Number	:

Provider Business Practice Location Address
First Line	:	851 E 5TH ST STE 108
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-3128
Country	:	US
Telephone Number	:	636-239-8633
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED MASTECTOMY FITTER
Name	:	MICHELLE R DOLLEY
Credential	:	CMF
Telephone Number	:	636-583-4181

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	08/22/2020

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