Provider Demographics
NPI:1639153083
Name:CAMEO BRA SHOP
Entity type:Organization
Organization Name:CAMEO BRA SHOP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY SUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TUTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-591-4118
Mailing Address - Street 1:1020 HINSDALE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-6802
Mailing Address - Country:US
Mailing Address - Phone:336-591-4118
Mailing Address - Fax:336-591-4118
Practice Address - Street 1:1020 HINSDALE RD
Practice Address - Street 2:
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-6802
Practice Address - Country:US
Practice Address - Phone:336-591-4118
Practice Address - Fax:336-591-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5978660001OtherCIGNA HEALTH CARE
NC7704224Medicaid
046FJOtherBCBS
NC5978660001OtherEMPLOYEES IDENTIFICATION
805501OtherPARTNERS
NC5978660001OtherCIGNA HEALTH CARE
805501OtherPARTNERS
NC7704224Medicaid