MEDICARE: LIFESHAPES BOUTIQUE 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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M2444	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1316047350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESHAPES BOUTIQUE INC

Provider Business Mailing Address
First Line	:	518 LAKEWOOD DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33510-4037
Country	:	US
Telephone Number	:	813-654-6968
Fax Number	:	813-655-6968

Provider Business Practice Location Address
First Line	:	518 LAKEWOOD DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33510-4037
Country	:	US
Telephone Number	:	813-654-6968
Fax Number	:	813-655-6968

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. FELICIA NORIEGA DICKEY
Credential	:
Telephone Number	:	813-629-6331

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	08/22/2020

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Directions to “LIFESHAPES BOUTIQUE INC ” Practice Location

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