Provider Demographics
NPI:1376508309
Name:ROBERTAS LOVELY LADIES BOUTIQUE
Entity Type:Organization
Organization Name:ROBERTAS LOVELY LADIES BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE PROPIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-467-0640
Mailing Address - Street 1:603 WEST DELMAR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:618-467-0640
Mailing Address - Fax:618-467-8819
Practice Address - Street 1:603 WEST DELMAR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-467-0640
Practice Address - Fax:618-467-8819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA1735332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL137024OtherBCBS OF MO
IL2375728OtherAETNA
269893OtherHEALTHLINK OF IL
L038503OtherTRICARE
IL5824316OtherAETNA
IL06020694OtherBCBS OF IL
ILBA7549138OtherMULTI PLAN OF IL
IL06020694OtherBCBS OF IL
=========OtherGHP OF IL
IL2375728OtherAETNA
=========OtherUNITED HEALTH CARE
IL0935370001Medicare ID - Type Unspecified