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General NPI Number Information
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NPI Number | 1548357965
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Entity Type | Organization
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Legal Business Name | ALICES BREAST PROSTHESIS SHOP
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 01/04/2008
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Provider Practice Location Address
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Address Line | 1748 HOOVER ROAD
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City | DEER GROVE
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State | IL
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Zip | 61243-9738
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Country | US
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Telephone | 815-438-6481
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Fax |
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Provider Business Mailing Address
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Address Line | 1748 HOOVER ROAD
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City | DEER GROVE
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State | IL
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Zip | 61243-9738
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Country | US
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Telephone | 815-438-6481
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ALICE C GARLAND
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Credential |
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Telephone | 815-438-6481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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