Provider Demographics
NPI:1295204261
Name:CHIC BOUTIQUE LLC
Entity Type:Organization
Organization Name:CHIC BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSSEFI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-588-0100
Mailing Address - Street 1:408 PITKIN HOLW
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5612
Mailing Address - Country:US
Mailing Address - Phone:212-470-5092
Mailing Address - Fax:
Practice Address - Street 1:168 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1901
Practice Address - Country:US
Practice Address - Phone:203-588-0100
Practice Address - Fax:203-588-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty