Healthcare Provider Details

I. General information

NPI: 1316693765
Provider Name (Legal Business Name): MADELINE ROSE MASTECTOMY BOUTIQUE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 07/26/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RANO BLVD
VESTAL NY
13850-2776
US

IV. Provider business mailing address

100 RANO BLVD
VESTAL NY
13850-2776
US

V. Phone/Fax

Practice location:
  • Phone: 607-296-2021
  • Fax: 607-296-2023
Mailing address:
  • Phone: 607-296-2021
  • Fax: 607-296-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. JAMIE LEIGH WALCK
Title or Position: OWNER
Credential: CMF
Phone: 607-296-2021