Provider Demographics
NPI:1346572781
Name:PRINCESS CORSET AND LINGERIE SHOP, LLC
Entity Type:Organization
Organization Name:PRINCESS CORSET AND LINGERIE SHOP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:JURGAITIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-755-3640
Mailing Address - Street 1:102 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1909
Mailing Address - Country:US
Mailing Address - Phone:203-755-3640
Mailing Address - Fax:
Practice Address - Street 1:102 GRAND STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:203-755-3640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies