Healthcare Provider Details

I. General information

NPI: 1669044905
Provider Name (Legal Business Name): THE MANNEQUIN QUEEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 CHIOS ISLAND RD APT 203
SEFFNER FL
33584-8377
US

IV. Provider business mailing address

3614 CHIOS ISLAND RD APT 203
SEFFNER FL
33584-8377
US

V. Phone/Fax

Practice location:
  • Phone: 813-928-1248
  • Fax: 813-999-4857
Mailing address:
  • Phone: 813-928-1248
  • Fax: 813-999-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: LAKEESHA S JAMES
Title or Position: OWNER
Credential:
Phone: 813-928-1248