Healthcare Provider Details

I. General information

NPI: 1629920004
Provider Name (Legal Business Name): ATALAYA FITS BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 HIGHMARKET ST
GEORGETOWN SC
29440-3121
US

IV. Provider business mailing address

1768 CALHOUN DR
GEORGETOWN SC
29440-6522
US

V. Phone/Fax

Practice location:
  • Phone: 843-833-8006
  • Fax: 843-833-8014
Mailing address:
  • Phone: 843-359-2533
  • Fax: 843-833-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State

VIII. Authorized Official

Name: DIONA A LEAK
Title or Position: OWNER
Credential: CMF
Phone: 843-359-2533