Provider Demographics
NPI:1154504645
Name:SUSAN SCHEFTICS MASTECTOMY BOUTIQUE
Entity type:Organization
Organization Name:SUSAN SCHEFTICS MASTECTOMY BOUTIQUE
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:5700 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-3200
Mailing Address - Country:US
Mailing Address - Phone:315-468-9743
Mailing Address - Fax:315-468-9744
Practice Address - Street 1:5700 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3200
Practice Address - Country:US
Practice Address - Phone:315-468-9743
Practice Address - Fax:315-468-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
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