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General NPI Number Information
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NPI Number | 1902202708
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Entity Type | Organization
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Legal Business Name | A BEAUTIFUL YOU MASTECTOMY BOUTIQUE
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Dates
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Enumeration Date | 11/06/2014
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Last Update Date | 11/06/2014
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Provider Practice Location Address
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Address Line | 2006 BLAINE ST
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City | CALDWELL
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State | ID
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Zip | 83605-4343
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Country | US
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Telephone | 208-985-5404
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Fax | 208-402-5959
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Provider Business Mailing Address
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Address Line | 2006 BLAINE ST
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City | CALDWELL
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State | ID
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Zip | 83605-4343
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Country | US
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Telephone | 208-985-5404
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Fax | 208-402-5959
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Authorized Official
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Title or Position | PRESIDENT
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Name | LEANNE KOVICK
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Credential | CFM
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Telephone | 208-985-5404
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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 | CFM02746
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License Number State | ID
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