MEDICARE: LOVE STRUCK VIRGIN REMY LLC

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	:	1568106573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOVE STRUCK VIRGIN REMY LLC

Provider Business Mailing Address
First Line	:	261 N LAMB BLVD UNIT B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-0505
Country	:	US
Telephone Number	:	314-574-8970
Fax Number	:

Provider Business Practice Location Address
First Line	:	261 N LAMB BLVD UNIT B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-0505
Country	:	US
Telephone Number	:	314-574-8970
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VICTORIA DANIELLE COTTON
Credential	:
Telephone Number	:	314-574-8970

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	05/03/2022

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