MEDICARE: MISS STEVENS FOR LINGERIE

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

General Provider Information

NPI Number	:	1467580423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISS STEVENS FOR LINGERIE

Provider Business Mailing Address
First Line	:	2235 S SEPULVEDA BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1811
Country	:	US
Telephone Number	:	310-278-7987
Fax Number	:	310-278-2593

Provider Business Practice Location Address
First Line	:	2235 S SEPULVEDA BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1811
Country	:	US
Telephone Number	:	310-278-7987
Fax Number	:	310-278-2593

Authorized Official
Title or Position	:	OWNER
Name	:	LESLIE DIANE VAUGHN
Credential	:	CFM
Telephone Number	:	310-278-7987

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/21/2010

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Directions to “MISS STEVENS FOR LINGERIE ” Practice Location

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