Provider Demographics
NPI:1538658950
Name:THE PINK ALTERNATIVE LLC
Entity Type:Organization
Organization Name:THE PINK ALTERNATIVE LLC
Other - Org Name:THE PINK ALTERNATIVE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CERTIFIED FITTER MASTECTOMY
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:HOLTON
Authorized Official - Last Name:NEWBY
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:334-446-3337
Mailing Address - Street 1:3000 HARTFORD HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4906
Mailing Address - Country:US
Mailing Address - Phone:334-446-3337
Mailing Address - Fax:334-446-3698
Practice Address - Street 1:3000 HARTFORD HWY STE 1
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4906
Practice Address - Country:US
Practice Address - Phone:334-446-3337
Practice Address - Fax:334-446-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL368224900000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1992217285Medicaid