MEDICARE: BOUTIQUE DE 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	:	1477742369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOUTIQUE DE LINGERIE

Provider Business Mailing Address
First Line	:	650 SAN BENITO ST STE 150
Second Line	:
City	:	HOLLISTER
State	:	CA
Zip	:	95023-3968
Country	:	US
Telephone Number	:	831-635-0722
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 SAN BENITO ST STE 150
Second Line	:
City	:	HOLLISTER
State	:	CA
Zip	:	95023-3968
Country	:	US
Telephone Number	:	831-635-0722
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEANNINE DIVINCENZO
Credential	:
Telephone Number	:	831-635-0722

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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Directions to “BOUTIQUE DE LINGERIE ” Practice Location

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