Provider Demographics
NPI:1376261255
Name:PHENOMENAL TRESSES LLC
Entity Type:Organization
Organization Name:PHENOMENAL TRESSES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIC ORTHOTIC PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THAMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-332-3434
Mailing Address - Street 1:1010 S MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-4658
Mailing Address - Country:US
Mailing Address - Phone:850-332-3434
Mailing Address - Fax:850-806-1883
Practice Address - Street 1:1010 S MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4658
Practice Address - Country:US
Practice Address - Phone:850-332-3434
Practice Address - Fax:850-806-1883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier