Provider Demographics
NPI:1508060443
Name:VERNA LEE STIVENDER
Entity Type:Organization
Organization Name:VERNA LEE STIVENDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MASTECTOMY CERT FITTER AND CO
Authorized Official - Prefix:MS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:STIVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-917-1771
Mailing Address - Street 1:1564 MIRAMONTE AVENUE
Mailing Address - Street 2:#A
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024
Mailing Address - Country:US
Mailing Address - Phone:650-917-1771
Mailing Address - Fax:650-917-1551
Practice Address - Street 1:1564 MIRAMONTE AVENUE
Practice Address - Street 2:#A
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024
Practice Address - Country:US
Practice Address - Phone:650-917-1771
Practice Address - Fax:650-917-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6173940001Medicare NSC