Healthcare Provider Details

I. General information

NPI: 1356522304
Provider Name (Legal Business Name): CAROLS PERSONAL MASTECTOMY BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 S MAIN ST
SALT LAKE CITY UT
84115-3748
US

IV. Provider business mailing address

3165 S MAIN ST
SALT LAKE CITY UT
84115-3748
US

V. Phone/Fax

Practice location:
  • Phone: 801-483-1262
  • Fax: 801-483-1287
Mailing address:
  • Phone: 801-483-1262
  • Fax: 801-483-1287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1744P3200X
License Number StateUT

VIII. Authorized Official

Name: GARY R STENQUIST
Title or Position: OWNER
Credential:
Phone: 801-483-1262