Healthcare Provider Details

I. General information

NPI: 1831473313
Provider Name (Legal Business Name): FAMOUS FOAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2397 SAN PABLO AVE
BERKELEY CA
94702-2055
US

IV. Provider business mailing address

50 MOUNT WHITNEY DR
SAN RAFAEL CA
94903-1037
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-9001
  • Fax:
Mailing address:
  • Phone: 415-491-4799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DAVID BRADSHAW
Title or Position: OWNER
Credential:
Phone: 415-491-4799