Healthcare Provider Details

I. General information

NPI: 1639429509
Provider Name (Legal Business Name): MASTECTOMY BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3486 DELTONA BLVD
SPRING HILL FL
34606-2997
US

IV. Provider business mailing address

3486 DELTONA BLVD
SPRING HILL FL
34606-2997
US

V. Phone/Fax

Practice location:
  • Phone: 352-683-9991
  • Fax: 352-683-1599
Mailing address:
  • Phone: 352-683-9991
  • Fax: 352-683-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. DEBORAH MISTRETTA
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 352-683-9991