Madeline Rose Mastectomy Boutique, LLC

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

Legal business name

MADELINE ROSE MASTECTOMY BOUTIQUE, LLC

Practice address

100 Rano Blvd
Vestal, NY 13850-2776

Phone

(607) 296-2021

Fax

(607) 296-2023

NPI assigned

Feb 24, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Jamie Leigh Walck, CMFNPI 1336805159

Title

Owner

Phone

(607) 296-2021

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jamie Leigh Walck

  • Mastectomy Fitter
  • Vestal, NY
  • NPI 1336805159

  Single Specialty

  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1645660800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658793600000",
    "number": "1316693765",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 RANO BLVD",
            "city": "VESTAL",
            "state": "NY",
            "postal_code": "138502776",
            "telephone_number": "607-296-2021",
            "fax_number": "607-296-2023"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 RANO BLVD",
            "city": "VESTAL",
            "state": "NY",
            "postal_code": "138502776",
            "telephone_number": "607-296-2021",
            "fax_number": "607-296-2023"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MADELINE ROSE MASTECTOMY BOUTIQUE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-24",
        "last_updated": "2022-07-26",
        "certification_date": "2022-05-31",
        "status": "A",
        "authorized_official_last_name": "WALCK",
        "authorized_official_first_name": "JAMIE",
        "authorized_official_middle_name": "LEIGH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "607-296-2021",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "CMF"
    },
    "taxonomies": [
        {
            "code": "224900000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Mastectomy Fitter",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ryan Paul Lowrie, PA
• Jodi Sue Lowry, LCSW-R, ACSW
• Luxottica of America Inc (Target Optical #4813)
• Megan Macken, NURSE PRACTITIONER
• Nathaniel Mackey, PHARMD
• Debbie Sue Maerz
• Sahar F Mahmoud, OD
• Mahmud S Khan MD
• John Marian Majewski III
• Cara Michelle Majka, RPH

• Durable Medical Equipment & Medical Supplies in Vestal, NY
• Providers in Vestal, NY by specialty
• Durable Medical Equipment & Medical Supplies in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.