Provider Demographics
NPI:1639429509
Name:MASTECTOMY BOUTIQUE
Entity Type:Organization
Organization Name:MASTECTOMY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MISTRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-683-9991
Mailing Address - Street 1:3486 DELTONA BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-2997
Mailing Address - Country:US
Mailing Address - Phone:352-683-9991
Mailing Address - Fax:352-683-1599
Practice Address - Street 1:3486 DELTONA BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-2997
Practice Address - Country:US
Practice Address - Phone:352-683-9991
Practice Address - Fax:352-683-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies