Healthcare Provider Details

I. General information

NPI: 1740565860
Provider Name (Legal Business Name): A NEW YOU PINK BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W ROBERTSON ST
BRANDON FL
33511-5112
US

IV. Provider business mailing address

106 W ROBERTSON ST
BRANDON FL
33511-5112
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-7465
  • Fax: 813-661-7465
Mailing address:
  • Phone: 813-661-7465
  • Fax: 813-661-7465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. GARY POOLE
Title or Position: OWNER
Credential:
Phone: 813-661-7465