Provider Demographics
NPI:1497866610
Name:MATTIE'S BRA SHOP
Entity Type:Organization
Organization Name:MATTIE'S BRA SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MATTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-730-8402
Mailing Address - Street 1:5514 HARVEST SCENE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2705
Mailing Address - Country:US
Mailing Address - Phone:410-730-8402
Mailing Address - Fax:410-730-8402
Practice Address - Street 1:8457 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:SUITE 17
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4209
Practice Address - Country:US
Practice Address - Phone:410-750-7950
Practice Address - Fax:410-730-8402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD361103505Medicaid