MEDICARE: BRILLIANT MEDICAL BOUTIQUE, LLC

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	CFM01117	TN
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1770751950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRILLIANT MEDICAL BOUTIQUE, LLC

Provider Business Mailing Address
First Line	:	6800 HARRIS PKWY STE 300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4262
Country	:	US
Telephone Number	:	682-312-9300
Fax Number	:	682-312-9133

Provider Business Practice Location Address
First Line	:	6800 HARRIS PKWY STE 300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4262
Country	:	US
Telephone Number	:	682-312-9300
Fax Number	:	682-312-9133

Authorized Official
Title or Position	:	OWNER
Name	:	JAMIE B MITTENDORF
Credential	:
Telephone Number	:	817-594-5868

Provider Enumeration Date	:	02/11/2008
Last Update Date	:	09/08/2022

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