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General NPI Number Information
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NPI Number | 1720229859
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Entity Type | Organization
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Legal Business Name | MAGNOLIAS POST-MASTECTOMY BOUTIQUE LLC
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Dates
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Enumeration Date | 03/19/2009
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Last Update Date | 03/19/2009
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Provider Practice Location Address
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Address Line | 625 S STATE ROAD 67
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City | MOORESVILLE
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State | IN
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Zip | 46158-2797
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Country | US
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Telephone | 317-831-3220
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Fax | 317-831-3321
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Provider Business Mailing Address
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Address Line | 625 S STATE ROAD 67
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City | MOORESVILLE
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State | IN
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Zip | 46158-2797
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Country | US
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Telephone | 317-831-3220
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Fax | 317-831-3321
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Authorized Official
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Title or Position | SINGLE MEMBER / OWNER
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Name | CHERRYL A JEDELE
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Credential |
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Telephone | 317-831-3220
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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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