=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447520903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEANS OF HOPE MASTECTOMY BOUTIQUE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2011
-----------------------------------------------------
Last Update Date | 12/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 COMMONS WAY BUILDING D
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08755-6428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-557-4673
-----------------------------------------------------
Fax | 732-557-4676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 COMMONS WAY BUILDING D
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08755-6428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-557-4673
-----------------------------------------------------
Fax | 732-557-4676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KAREN ANN DONOHUE
-----------------------------------------------------
Credential | CFM
-----------------------------------------------------
Telephone | 732-557-4673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------