Healthcare Provider Details

I. General information

NPI: 1245823392
Provider Name (Legal Business Name): THE MANE MASTERPIECE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5357 WYNDTREE LN SE
GRAND RAPIDS MI
49548-0837
US

IV. Provider business mailing address

5357 WYNDTREE LN SE
GRAND RAPIDS MI
49548-0837
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-9909
  • Fax:
Mailing address:
  • Phone: 616-916-9909
  • 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: MIKAYLA MCMATH
Title or Position: OWNER
Credential:
Phone: 616-916-9909