Provider Demographics
NPI:1982739603
Name:CONNIES MASTECTOMY BOUTIQUE INC
Entity type:Organization
Organization Name:CONNIES MASTECTOMY BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, TREASURER, DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:CRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-795-5223
Mailing Address - Street 1:0430 NE 3RD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-4244
Mailing Address - Country:US
Mailing Address - Phone:352-795-5223
Mailing Address - Fax:352-795-6390
Practice Address - Street 1:430 NE 3RD STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4244
Practice Address - Country:US
Practice Address - Phone:352-795-5223
Practice Address - Fax:352-795-6390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0467350001Medicare NSC