Provider Demographics
NPI:1265433171
Name:A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC.
Entity type:Organization
Organization Name:A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:AGAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-978-8287
Mailing Address - Street 1:2950 N STATE ROAD 7 STE 103
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5748
Mailing Address - Country:US
Mailing Address - Phone:954-978-8287
Mailing Address - Fax:954-978-9059
Practice Address - Street 1:2950 N STATE ROAD 7 STE 103
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5748
Practice Address - Country:US
Practice Address - Phone:954-978-8287
Practice Address - Fax:954-978-9059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1187390002335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL283302OtherAV-MED PROVIDER NUMBER
FL9490689001OtherCIGNA PROVIDER
FLM2726OtherBC/BS OF FLORIDA-MARGATE
FLM2420OtherBC/BS OF FLORIDA
FLM2420OtherBC/BS OF FLORIDA
FLM2726OtherBC/BS OF FLORIDA-MARGATE
FL283302OtherAV-MED PROVIDER NUMBER
FL=========OtherUNITED HEALTHCARE
FL=========OtherHUMANA HEALTH PLANS
FL=========OtherTAX I.D.
FL=========OtherAMERICAS HEALTH CHOICE
FL1187390001Medicare NSC