=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851006944
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASSION UNDONE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2023
-----------------------------------------------------
Last Update Date | 01/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 REMOUNT RD STE C-1749
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-6458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-326-2075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 REMOUNT RD STE C-1749
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-6458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-326-2075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORGANIZER/ MEMBER
-----------------------------------------------------
Name | DEHERDA ROCHELLE BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-464-4606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------