Provider Demographics
NPI:1134110802
Name:PINK RIBBON MASTECTOMY, INC.
Entity Type:Organization
Organization Name:PINK RIBBON MASTECTOMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RENEE'
Authorized Official - Last Name:HEIDE-MCDOUGALL
Authorized Official - Suffix:
Authorized Official - Credentials:RFM
Authorized Official - Phone:218-846-1800
Mailing Address - Street 1:101 GRAYSTONE PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3043
Mailing Address - Country:US
Mailing Address - Phone:218-846-1800
Mailing Address - Fax:218-846-1803
Practice Address - Street 1:101 GRAYSTONE PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3043
Practice Address - Country:US
Practice Address - Phone:218-846-1800
Practice Address - Fax:218-846-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4742020001Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION