Provider Demographics
NPI:1295042299
Name:SANTE' MAMA LLC
Entity Type:Organization
Organization Name:SANTE' MAMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-253-2229
Mailing Address - Street 1:113 NE 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2541
Mailing Address - Country:US
Mailing Address - Phone:360-253-2229
Mailing Address - Fax:360-944-0606
Practice Address - Street 1:113 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2541
Practice Address - Country:US
Practice Address - Phone:360-253-2229
Practice Address - Fax:360-944-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-12
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2009709Medicaid
WA6902530001Medicare NSC