Organization
MATTIE'S BRA SHOP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MATTIE M. STANFORD (OWNER)
(410) 730-8402
Entity
Organization
Contact information
Practice address
8457 BALTIMORE NATIONAL PIKE, SUITE 17, ELLICOTT CITY, MD 21043-4209
(410) 750-7950
(410) 730-8402
Mailing address
5514 HARVEST SCENE CT, COLUMBIA, MD 21044-2705
(410) 730-8402
(410) 730-8402
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
361103505
—
MD
Enumeration date
08/31/2006
Last updated
06/18/2008
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