Healthcare Provider Details

I. General information

NPI: 1639570559
Provider Name (Legal Business Name): LE BUSTIERE BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 COLUMBIA RD NW #2
WASHINGTON DC
20009-2881
US

IV. Provider business mailing address

1744 COLUMBIA RD NW #2
WASHINGTON DC
20009-2881
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8080
  • Fax: 202-745-8081
Mailing address:
  • Phone: 202-745-8080
  • Fax: 202-745-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number400314900285
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number400314900285
License Number StateDC

VIII. Authorized Official

Name: STEPHANIE JACEK
Title or Position: MANAGER
Credential:
Phone: 202-745-8080