Organization
MASTEC WOMENS BOUTIQUE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VIRGIE AMMERMAN (CEO/PRESIDENT)
(269) 598-7765
Entity
Organization
Contact information
Practice address
524 E MILHAM AVE, PORTAGE, MI 49002-1473
(269) 373-6223
(269) 373-6223
Mailing address
524 E MILHAM AVE, SUITE B, PORTAGE, MI 49002
(269) 373-6223
(269) 373-4720
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
540C903700
BLUE CROSS
MI
Enumeration date
12/18/2006
Last updated
10/19/2016
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