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General NPI Number Information
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NPI Number | 1316693765
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Entity Type | Organization
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Legal Business Name | MADELINE ROSE MASTECTOMY BOUTIQUE, LLC
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Dates
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Enumeration Date | 02/24/2022
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 100 RANO BLVD
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City | VESTAL
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State | NY
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Zip | 13850-2776
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Country | US
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Telephone | 607-296-2021
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Fax | 607-296-2023
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Provider Business Mailing Address
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Address Line | 100 RANO BLVD
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City | VESTAL
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State | NY
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Zip | 13850-2776
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Country | US
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Telephone | 607-296-2021
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Fax | 607-296-2023
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Authorized Official
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Title or Position | OWNER
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Name | MS. JAMIE LEIGH WALCK
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Credential | CMF
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Telephone | 607-296-2021
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224900000X
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Taxonomy Name | Mastectomy Fitter
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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