Healthcare Provider Details

I. General information

NPI: 1245363076
Provider Name (Legal Business Name): THE MASTECTOMY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 S NOLAND RD SUITE I
INDEPENDENCE MO
64055-7313
US

IV. Provider business mailing address

4201 S NOLAND RD SUITE I
INDEPENDENCE MO
64055-7313
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-3447
  • Fax: 816-373-3447
Mailing address:
  • Phone: 816-373-3447
  • Fax: 816-373-3447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCFM01450
License Number StateMO

VIII. Authorized Official

Name: DIXIE N STRETZ
Title or Position: CO OWNER
Credential:
Phone: 816-373-3447