=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558760611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A BEAUTIFUL YOU MASTECTOMY BOUTIQUE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2006 BLAINE ST
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-985-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2006 BLAINE ST
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-985-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MRS. LEANNE M KOVICK
-----------------------------------------------------
Credential | CFM
-----------------------------------------------------
Telephone | 208-985-5404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | CFM02746
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------