MEDICARE: THE BRA 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	335E00000X	Prosthetic/Orthotic Supplier	C17478	TX

General Provider Information

NPI Number	:	1518145788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BRA SHOP

Provider Business Mailing Address
First Line	:	6231 OAKMONT BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2812
Country	:	US
Telephone Number	:	817-263-0014
Fax Number	:	817-263-5779

Provider Business Practice Location Address
First Line	:	6231 OAKMONT BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2812
Country	:	US
Telephone Number	:	817-263-0014
Fax Number	:	817-263-5779

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SYLVIA DEANNA JONES
Credential	:	B.O.C.
Telephone Number	:	817-263-0014

Provider Enumeration Date	:	02/09/2008
Last Update Date	:	02/09/2008

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