Provider Demographics
NPI:1013014240
Name:CAROL'S PERSONAL MASTECTOMY BOUTIQUE OF SOUTHERN UTAH LLC
Entity Type:Organization
Organization Name:CAROL'S PERSONAL MASTECTOMY BOUTIQUE OF SOUTHERN UTAH LLC
Other - Org Name:CAROLS POST MASTECTOMY SPEC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:435-688-0452
Mailing Address - Street 1:1490 E FOREMASTER DR STE 310
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4504
Mailing Address - Country:US
Mailing Address - Phone:435-688-0452
Mailing Address - Fax:435-688-0453
Practice Address - Street 1:1490 E FOREMASTER DR STE 310
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4504
Practice Address - Country:US
Practice Address - Phone:435-688-0452
Practice Address - Fax:435-688-0453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid