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General NPI Number Information
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NPI Number | 1699458380
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Entity Type | Organization
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Legal Business Name | PREMIER MASTECTOMY VENDOR LLC
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Dates
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Enumeration Date | 08/09/2023
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Last Update Date | 12/20/2023
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Provider Practice Location Address
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Address Line | 5911 MONTICELLO DR STE B
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City | MONTGOMERY
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State | AL
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Zip | 36117-1940
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Country | US
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Telephone | 629-279-5720
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Fax |
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Provider Business Mailing Address
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Address Line | 5911 MONTICELLO DR STE B
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City | MONTGOMERY
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State | AL
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Zip | 36117-1940
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Country | US
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Telephone | 629-279-5720
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | MS. JASMINE BEAN
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Credential |
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Telephone | 629-279-5270
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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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 | 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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