Healthcare Provider Details

I. General information

NPI: 1730834771
Provider Name (Legal Business Name): SASSY SISTAS BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 W STATE ROAD 436 STE 1005
ALTAMONTE SPRINGS FL
32714-3055
US

IV. Provider business mailing address

851 W STATE ROAD 436 STE 1005
ALTAMONTE SPRINGS FL
32714-3055
US

V. Phone/Fax

Practice location:
  • Phone: 407-383-0643
  • Fax:
Mailing address:
  • Phone: 407-383-0643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. EBONI RAINEY-HAYNES
Title or Position: CO-OWNER
Credential:
Phone: 407-383-0643