Provider Demographics
NPI:1407994148
Name:MONUMENT IND.
Entity Type:Organization
Organization Name:MONUMENT IND.
Other - Org Name:MONUMENT WIGS & BREASTFORMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FITTER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RFM
Authorized Official - Phone:970-257-1317
Mailing Address - Street 1:241 GRAND AVE
Mailing Address - Street 2:SUITE # 6
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2262
Mailing Address - Country:US
Mailing Address - Phone:970-257-1317
Mailing Address - Fax:970-242-2406
Practice Address - Street 1:241 GRAND AVE
Practice Address - Street 2:SUITE #6
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2262
Practice Address - Country:US
Practice Address - Phone:970-257-1317
Practice Address - Fax:970-242-2406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23917970000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherFEDERAL EIN#
CO0251870001Medicare NSC
CO0251870001Medicare PIN