Provider Demographics
NPI:1750554960
Name:SIMPLY THE BREAST, LLC
Entity type:Organization
Organization Name:SIMPLY THE BREAST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:HORACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-973-8740
Mailing Address - Street 1:500 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2005
Mailing Address - Country:US
Mailing Address - Phone:217-342-6266
Mailing Address - Fax:217-342-6269
Practice Address - Street 1:500 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2005
Practice Address - Country:US
Practice Address - Phone:217-342-6266
Practice Address - Fax:217-342-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography