=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114195062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MMJ COCOS BOUTIQUE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 921 RIDGE RD # 2
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-836-0011
-----------------------------------------------------
Fax | 219-836-0011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 921 RIDGE RD # 2
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-836-0011
-----------------------------------------------------
Fax | 219-836-0011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARISOL PATINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-836-0011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------