Healthcare Provider Details

I. General information

NPI: 1295042299
Provider Name (Legal Business Name): SANTE' MAMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2010
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NE 92ND AVE
VANCOUVER WA
98664-2541
US

IV. Provider business mailing address

113 NE 92ND AVE
VANCOUVER WA
98664-2541
US

V. Phone/Fax

Practice location:
  • Phone: 360-253-2229
  • Fax: 360-944-0606
Mailing address:
  • Phone: 360-253-2229
  • Fax: 360-944-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. ERICA MATTESON
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-253-2229