Provider Demographics
NPI:1083960801
Name:FABULOUS WEAVE , LLC
Entity Type:Organization
Organization Name:FABULOUS WEAVE , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RNCONSULT FOR CRANIAL PROSTHESIS
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:301-609-0845
Mailing Address - Street 1:10595 SOURWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5730
Mailing Address - Country:US
Mailing Address - Phone:301-645-8765
Mailing Address - Fax:301-645-9611
Practice Address - Street 1:10595 SOURWOOD AVE
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5730
Practice Address - Country:US
Practice Address - Phone:301-645-8765
Practice Address - Fax:301-645-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment