Healthcare Provider Details

I. General information

NPI: 1962516823
Provider Name (Legal Business Name): WOMENS SURGICAL BOUTIQUE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 B BROADWAY
MALVERNE NY
11565-1652
US

IV. Provider business mailing address

112 B BROADWAY
MALVERNE NY
11565-1652
US

V. Phone/Fax

Practice location:
  • Phone: 516-292-1320
  • Fax: 516-292-1323
Mailing address:
  • Phone: 516-292-1320
  • Fax: 516-292-1323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. DIANE E LIPMAN
Title or Position: PRESIDENT
Credential: CMF
Phone: 516-292-1320