Provider Demographics
NPI:1295387041
Name:BOUTIQUE PHYSIO, INC
Entity Type:Organization
Organization Name:BOUTIQUE PHYSIO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-802-7337
Mailing Address - Street 1:909 PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3012
Mailing Address - Country:US
Mailing Address - Phone:314-802-7337
Mailing Address - Fax:
Practice Address - Street 1:909 PURDUE AVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY CITY
Practice Address - State:MO
Practice Address - Zip Code:63130-3012
Practice Address - Country:US
Practice Address - Phone:314-802-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty