Provider Demographics
NPI:1245363076
Name:THE MASTECTOMY CENTER
Entity type:Organization
Organization Name:THE MASTECTOMY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:STRETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-373-3447
Mailing Address - Street 1:4201 S NOLAND RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7313
Mailing Address - Country:US
Mailing Address - Phone:816-373-3447
Mailing Address - Fax:816-373-3447
Practice Address - Street 1:4201 S NOLAND RD
Practice Address - Street 2:SUITE I
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-7313
Practice Address - Country:US
Practice Address - Phone:816-373-3447
Practice Address - Fax:816-373-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCFM01450335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
36532017OtherBCBS
36532017OtherBCBS