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General NPI Number Information
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NPI Number | 1376508309
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Entity Type | Organization
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Legal Business Name | ROBERTAS LOVELY LADIES BOUTIQUE
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 06/18/2015
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Provider Practice Location Address
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Address Line | 603 WEST DELMAR
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City | ALTON
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State | IL
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Zip | 62002
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Country | US
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Telephone | 618-467-0640
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Fax | 618-467-8819
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Provider Business Mailing Address
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Address Line | 603 WEST DELMAR
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City | ALTON
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State | IL
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Zip | 62002
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Country | US
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Telephone | 618-467-0640
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Fax | 618-467-8819
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Authorized Official
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Title or Position | OWNER SOLE PROPIETOR
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Name | MRS. ROBERTA J JAYNES
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Credential |
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Telephone | 618-467-0640
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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 | A1735
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License Number State | IL
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