MEDICARE: DORIS W MENG BRA BOUTIQUE

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	332BC3200X	Customized Equipment (DME)	C07011400034776	NV

General Provider Information

NPI Number	:	1093960619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DORIS W MENG BRA BOUTIQUE

Provider Business Mailing Address
First Line	:	2375 S JONES BLVD
Second Line	:	SUITE 14
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3169
Country	:	US
Telephone Number	:	702-362-1579
Fax Number	:	702-368-4609

Provider Business Practice Location Address
First Line	:	2375 S JONES BLVD
Second Line	:	SUITE 14
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3169
Country	:	US
Telephone Number	:	702-362-1579
Fax Number	:	702-368-4609

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DORIS WEST MENG
Credential	:
Telephone Number	:	702-362-1579

Provider Enumeration Date	:	11/24/2008
Last Update Date	:	11/24/2008

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