MEDICARE: PINK RIBBON BOUTIQUE CHIPPEWA VALLEY 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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		NOT ISSUED

General Provider Information

NPI Number	:	1609583442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINK RIBBON BOUTIQUE CHIPPEWA VALLEY LLC

Provider Business Mailing Address
First Line	:	2829 COUNTY HIGHWAY I STE 3
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-2678
Country	:	US
Telephone Number	:	715-492-4068
Fax Number	:	715-723-4451

Provider Business Practice Location Address
First Line	:	2829 COUNTY HIGHWAY I STE 3
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-2678
Country	:	US
Telephone Number	:	715-492-4068
Fax Number	:	715-723-4451

Authorized Official
Title or Position	:	OWNER
Name	:	ARIANNE FOX
Credential	:	PT
Telephone Number	:	715-226-1416

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	11/01/2022

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