MEDICARE: PETTICOAT FAIR INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	17	TX

General Provider Information

NPI Number	:	1033219175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETTICOAT FAIR INC

Provider Business Mailing Address
First Line	:	PO BOX 10676
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78766-1676
Country	:	US
Telephone Number	:	512-454-2900
Fax Number	:	512-454-3381

Provider Business Practice Location Address
First Line	:	7739 NORTHCROSS DR
Second Line	:	SUITE M
City	:	AUSTIN
State	:	TX
Zip	:	78757-1700
Country	:	US
Telephone Number	:	512-454-2900
Fax Number	:	512-454-3381

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. KIRK ANDREWS
Credential	:
Telephone Number	:	512-454-2900

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/21/2022

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