MEDICARE: HI FASHION BOUTIQUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	691-021	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	691-021	OTHER	TX	TEXAS COSMETOLOGY

General Provider Information

NPI Number	:	1598777831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HI FASHION BOUTIQUE

Provider Business Mailing Address
First Line	:	4522 FREDERICKSBURG RD
Second Line	:	A35
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-6521
Country	:	US
Telephone Number	:	210-732-7070
Fax Number	:

Provider Business Practice Location Address
First Line	:	4522 FREDERICKSBURG RD
Second Line	:	A35
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-6521
Country	:	US
Telephone Number	:	210-732-7070
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT/OWNER
Name	:	MRS. MARIA DEL SOCCORRO WILSON
Credential	:	OPERATOR, LICENSED
Telephone Number	:	210-732-7070

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	03/20/2011

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Directions to “HI FASHION BOUTIQUE ” Practice Location

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