MEDICARE: BOOB SHOP

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32073080122	OTHER	TX	TEXAS TAXPAYER ID

General Provider Information

NPI Number	:	1225650666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOOB SHOP

Provider Business Mailing Address
First Line	:	250 TREELINE PARK APT 302
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-7401
Country	:	US
Telephone Number	:	757-706-5571
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 BROADWAY ST STE 700
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5739
Country	:	US
Telephone Number	:	757-706-5571
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BROOKE STRACHAN
Credential	:
Telephone Number	:	757-706-5571

Provider Enumeration Date	:	05/07/2020
Last Update Date	:	07/24/2020

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Directions to “BOOB SHOP ” Practice Location

Language	Start Address	Practice Location

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