Provider Demographics
NPI:1649421884
Name:D.B.A MOM'S MASTECTOMY
Entity Type:Organization
Organization Name:D.B.A MOM'S MASTECTOMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-464-6001
Mailing Address - Street 1:415 N 66TH ST.
Mailing Address - Street 2:SUITE 8
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505
Mailing Address - Country:US
Mailing Address - Phone:402-464-6001
Mailing Address - Fax:402-464-6669
Practice Address - Street 1:415 N 66TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2431
Practice Address - Country:US
Practice Address - Phone:402-464-6001
Practice Address - Fax:402-464-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6163200001Medicare NSC