=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083023907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASTECTOMY ESSENTIALS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2014
-----------------------------------------------------
Last Update Date | 08/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 CORPORATE DR STE 140
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70360-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-850-2729
-----------------------------------------------------
Fax | 985-876-6853
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 CORPORATE DR STE 140
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70360-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-850-2729
-----------------------------------------------------
Fax | 985-876-6853
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. EVANGELINE LECOMPTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-852-9025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | OC23303
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------