Provider Demographics
NPI:1952417859
Name:SUSAN SCHEFTICS MASTECTOMY BOUTIQUE
Entity Type:Organization
Organization Name:SUSAN SCHEFTICS MASTECTOMY BOUTIQUE
Other - Org Name:LADY JANE MASTECTOMY BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHEFTIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-498-9086
Mailing Address - Street 1:892 E BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205
Mailing Address - Country:US
Mailing Address - Phone:315-498-9086
Mailing Address - Fax:315-498-9087
Practice Address - Street 1:892 E BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205
Practice Address - Country:US
Practice Address - Phone:315-498-9086
Practice Address - Fax:315-498-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01505022Medicaid
NY01505022Medicaid