Healthcare Provider Details

I. General information

NPI: 1699458380
Provider Name (Legal Business Name): PREMIER MASTECTOMY VENDOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 MONTICELLO DR STE B
MONTGOMERY AL
36117-1940
US

IV. Provider business mailing address

5911 MONTICELLO DR STE B
MONTGOMERY AL
36117-1940
US

V. Phone/Fax

Practice location:
  • Phone: 629-279-5720
  • Fax:
Mailing address:
  • Phone: 629-279-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State

VIII. Authorized Official

Name: MS. JASMINE BEAN
Title or Position: CO-OWNER
Credential:
Phone: 629-279-5270