Healthcare Provider Details

I. General information

NPI: 1083622740
Provider Name (Legal Business Name): LILLYS FINE LINGERIE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 STATION PLAZA
GLEN HEAD NY
11545
US

IV. Provider business mailing address

5 STATION PLAZA
GLEN HEAD NY
11545
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-8109
  • Fax:
Mailing address:
  • Phone: 516-674-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANE M BRUSCELLA
Title or Position: OWNER
Credential: CMF
Phone: 516-674-8109