=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942475181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAVENDER WISP LINGERIE CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2008
-----------------------------------------------------
Last Update Date | 07/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78 RICHMOND STREET
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-623-8665
-----------------------------------------------------
Fax | 973-623-8665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78 RICHMOND STREET
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-623-8665
-----------------------------------------------------
Fax | 973-623-8665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER OWNER
-----------------------------------------------------
Name | PATRICIA M. JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-623-8161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------