=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164770335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHBOUTIQUE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2012
-----------------------------------------------------
Last Update Date | 03/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1322 N BECKLEY AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75203-1254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-948-3999
-----------------------------------------------------
Fax | 214-948-3993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 N 6TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-6606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-758-9904
-----------------------------------------------------
Fax | 903-236-9786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / MANAGER
-----------------------------------------------------
Name | VICKI D JONES
-----------------------------------------------------
Credential | CMF, COF
-----------------------------------------------------
Telephone | 903-758-9904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1000975
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------