Provider Demographics
NPI:1194904540
Name:PANSY'S POST MASTECTOMY BOUTIQUE, INC.
Entity type:Organization
Organization Name:PANSY'S POST MASTECTOMY BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GOEWEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-232-6600
Mailing Address - Street 1:100 REDMOND RD NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1536
Mailing Address - Country:US
Mailing Address - Phone:706-232-6600
Mailing Address - Fax:706-232-6677
Practice Address - Street 1:100 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1536
Practice Address - Country:US
Practice Address - Phone:706-232-6600
Practice Address - Fax:706-232-6677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000484332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA585652876BMedicaid
GA585652876BMedicaid