Provider Demographics
NPI:1417638891
Name:TAYLOR MADE BOUTIQUE & BEAUTY SUPPLY LLC
Entity Type:Organization
Organization Name:TAYLOR MADE BOUTIQUE & BEAUTY SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LATOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-681-6546
Mailing Address - Street 1:2000 S UNIVERSITY AVE STE L
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-3603
Mailing Address - Country:US
Mailing Address - Phone:501-615-8007
Mailing Address - Fax:
Practice Address - Street 1:2000 S UNIVERSITY AVE STE L
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-3603
Practice Address - Country:US
Practice Address - Phone:501-615-8007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier