Healthcare Provider Details

I. General information

NPI: 1316128747
Provider Name (Legal Business Name): SECOND TO NATURE MASTECTOMY BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 STATE ST UNIT A
GREENSBORO NC
27405-5659
US

IV. Provider business mailing address

PO BOX 7968
GREENSBORO NC
27417-0968
US

V. Phone/Fax

Practice location:
  • Phone: 336-274-2003
  • Fax: 336-274-2052
Mailing address:
  • Phone: 336-274-2003
  • Fax: 336-274-2052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number600186564
License Number StateNC

VIII. Authorized Official

Name: RAMONA RAE HERTZELL
Title or Position: OWNER
Credential: CFM
Phone: 336-274-2003