MEDICARE: PRINCESS MANES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1013736214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCESS MANES

Provider Business Mailing Address
First Line	:	3123 RUSSELL AVE N # 1
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1018
Country	:	US
Telephone Number	:	612-743-2688
Fax Number	:

Provider Business Practice Location Address
First Line	:	4171 LYNDALE AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1737
Country	:	US
Telephone Number	:	612-451-9721
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LA TISHA MILLER
Credential	:
Telephone Number	:	612-743-2688

Provider Enumeration Date	:	10/07/2024
Last Update Date	:	10/07/2024

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Directions to “PRINCESS MANES ” Practice Location

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