Provider Demographics
NPI:1740438696
Name:RECREATE MASTECTOMY PRODUCTS & BOUTIQUE
Entity type:Organization
Organization Name:RECREATE MASTECTOMY PRODUCTS & BOUTIQUE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:406-549-0921
Mailing Address - Street 1:116 SOUTH AVE W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8116
Mailing Address - Country:US
Mailing Address - Phone:406-721-4242
Mailing Address - Fax:
Practice Address - Street 1:116 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8116
Practice Address - Country:US
Practice Address - Phone:406-721-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOULA ORTHOTICS & PROSTHETICS LABORATORY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0287610002Medicare NSC