MEDICARE: MASTECTOMY SHOPPE, 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	:	1922763150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MASTECTOMY SHOPPE, LLC

Provider Business Mailing Address
First Line	:	9700 REDSTONE DR STE 200
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-5409
Country	:	US
Telephone Number	:	803-548-8627
Fax Number	:	803-548-8630

Provider Business Practice Location Address
First Line	:	9700 REDSTONE DR STE 200
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-5409
Country	:	US
Telephone Number	:	803-548-8627
Fax Number	:	803-548-8630

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	CHRISTEN E TESE
Credential	:
Telephone Number	:	561-573-9596

Provider Enumeration Date	:	11/02/2021
Last Update Date	:	03/31/2022

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