Provider Demographics
NPI:1083622740
Name:LILLYS FINE LINGERIE, INC.
Entity Type:Organization
Organization Name:LILLYS FINE LINGERIE, INC.
Other - Org Name:DBA LILLYS MASTECTOMY & WIG BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRUSCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:516-674-8109
Mailing Address - Street 1:5 STATION PLAZA
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545
Mailing Address - Country:US
Mailing Address - Phone:516-674-8109
Mailing Address - Fax:
Practice Address - Street 1:5 STATION PLAZA
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545
Practice Address - Country:US
Practice Address - Phone:516-674-8109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0465270001Medicare ID - Type UnspecifiedMASTECTOMY BOUTIQUE
NYC85181Medicare UPIN