Provider Demographics
NPI:1063699064
Name:SECRET BENEATH
Entity type:Organization
Organization Name:SECRET BENEATH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BYAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-364-7631
Mailing Address - Street 1:130 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-2035
Mailing Address - Country:US
Mailing Address - Phone:207-364-7631
Mailing Address - Fax:207-364-7631
Practice Address - Street 1:130 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2035
Practice Address - Country:US
Practice Address - Phone:207-364-7631
Practice Address - Fax:207-364-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier