Provider Demographics
NPI:1043424849
Name:BOSOM BUDDIES, LLC
Entity Type:Organization
Organization Name:BOSOM BUDDIES, LLC
Other - Org Name:GIE GIE LINGERIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTRANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:610-296-7626
Mailing Address - Street 1:36 CHESTNUT RD
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1565
Mailing Address - Country:US
Mailing Address - Phone:610-296-7626
Mailing Address - Fax:610-296-7620
Practice Address - Street 1:36 CHESTNUT RD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1565
Practice Address - Country:US
Practice Address - Phone:610-296-7626
Practice Address - Fax:610-296-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAZ6860335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1981984OtherHIGHMARK
PA0002039000OtherINDEPENDENCE BLUE CROSS
PA1981984OtherHIGHMARK
PA5916460001Medicare Oscar/Certification