Healthcare Provider Details

I. General information

NPI: 1598777831
Provider Name (Legal Business Name): HI FASHION BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 03/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4522 FREDERICKSBURG RD A35
SAN ANTONIO TX
78201-6521
US

IV. Provider business mailing address

4522 FREDERICKSBURG RD A35
SAN ANTONIO TX
78201-6521
US

V. Phone/Fax

Practice location:
  • Phone: 210-732-7070
  • Fax:
Mailing address:
  • Phone: 210-732-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number691-021
License Number StateTX

VIII. Authorized Official

Name: MRS. MARIA DEL SOCCORRO WILSON
Title or Position: CEO/PRESIDENT/OWNER
Credential: OPERATOR, LICENSED
Phone: 210-732-7070