Provider Demographics
NPI:1316128747
Name:SECOND TO NATURE MASTECTOMY BOUTIQUE
Entity type:Organization
Organization Name:SECOND TO NATURE MASTECTOMY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HERTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:336-274-2003
Mailing Address - Street 1:PO BOX 7968
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27417-0968
Mailing Address - Country:US
Mailing Address - Phone:336-274-2003
Mailing Address - Fax:336-274-2052
Practice Address - Street 1:500 STATE ST UNIT A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5659
Practice Address - Country:US
Practice Address - Phone:336-274-2003
Practice Address - Fax:336-274-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC600186564335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0360AOtherBCBS
NC7702598Medicaid
NC7702598Medicaid