Provider Demographics
NPI:1235378746
Name:UNIQUE BOUTIQUE LLC
Entity Type:Organization
Organization Name:UNIQUE BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:DECARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-626-5610
Mailing Address - Street 1:125 S MIRAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3225
Mailing Address - Country:US
Mailing Address - Phone:321-626-5610
Mailing Address - Fax:
Practice Address - Street 1:125 S MIRAMAR AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3225
Practice Address - Country:US
Practice Address - Phone:321-626-5610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-08
Last Update Date:2009-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier