MEDICARE: THE FORMS BOUTIQUE, INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689768376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FORMS BOUTIQUE, INC.

Provider Business Mailing Address
First Line	:	3308 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4024
Country	:	US
Telephone Number	:	803-738-8400
Fax Number	:	803-738-8498

Provider Business Practice Location Address
First Line	:	3308 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4024
Country	:	US
Telephone Number	:	803-738-8400
Fax Number	:	803-738-8498

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. AMY D. MCLELLAN
Credential	:	RFM, CMF
Telephone Number	:	803-799-7096

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	03/17/2020

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Directions to “THE FORMS BOUTIQUE, INC. ” Practice Location

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