Healthcare Provider Details

I. General information

NPI: 1639834831
Provider Name (Legal Business Name): SUGAR ME LACE AND MINK BAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 DEMETROPOLIS RD
MOBILE AL
36693-4641
US

IV. Provider business mailing address

5380 MOSSBERG DR S
THEODORE AL
36582-7322
US

V. Phone/Fax

Practice location:
  • Phone: 251-490-7937
  • Fax: 251-666-6434
Mailing address:
  • Phone: 251-490-7937
  • Fax: 251-666-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRACEY R MORGAN
Title or Position: OWNER
Credential:
Phone: 251-490-7937