Provider Demographics
NPI:1528242237
Name:MIZZ RAE'S LLC
Entity type:Organization
Organization Name:MIZZ RAE'S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO - EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-327-1041
Mailing Address - Street 1:5278 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-6338
Mailing Address - Country:US
Mailing Address - Phone:617-327-1041
Mailing Address - Fax:
Practice Address - Street 1:5278 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:617-327-1041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6080520001Medicare NSC