Healthcare Provider Details

I. General information

NPI: 1154045888
Provider Name (Legal Business Name): BIRCH BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 CLEMONT ST STE #8
ANTIGO WI
54409-1988
US

IV. Provider business mailing address

612 CLEMONT ST STE #8
ANTIGO WI
54409-1988
US

V. Phone/Fax

Practice location:
  • Phone: 715-350-7174
  • Fax: 715-716-4330
Mailing address:
  • Phone: 715-350-7174
  • Fax: 715-716-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GRETA TOMANY
Title or Position: OWNER
Credential: RN,CMF
Phone: 715-350-7174