Provider Demographics
NPI:1396506937
Name:DECORATED DOMES
Entity type:Organization
Organization Name:DECORATED DOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHINA
Authorized Official - Middle Name:
Authorized Official - Last Name:UPSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-435-0266
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 EAGLE LN
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3613
Practice Address - Country:US
Practice Address - Phone:310-435-0266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No251V00000XAgenciesVoluntary or Charitable