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General NPI Number Information
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NPI Number | 1194100800
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Entity Type | Organization
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Legal Business Name | THE PINK BOUTIQUE
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Dates
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Enumeration Date | 07/23/2015
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Last Update Date | 07/23/2015
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Provider Practice Location Address
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Address Line | 7410 JOHN SMITH STE 210
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City | SAN ANTONIO
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State | TX
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Zip | 78229-4421
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Country | US
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Telephone | 210-614-3804
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Fax | 210-614-3805
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Provider Business Mailing Address
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Address Line | PO BOX 29366
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City | SAN ANTONIO
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State | TX
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Zip | 78229-0366
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Country | US
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Telephone | 210-614-3804
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Fax | 210-614-3805
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Authorized Official
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Title or Position | CEO
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Name | MS. ALICIA CORREA
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Credential | RN CMF
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Telephone | 210-614-3804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 0105777
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License Number State | TX
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