Provider Demographics
NPI:1437192168
Name:REFLECTIONS WELLNESS BOUTIQUE LLC
Entity Type:Organization
Organization Name:REFLECTIONS WELLNESS BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:VANDENBURGH
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-594-4949
Mailing Address - Street 1:14051 SAINT FRANCIS BOULEVARD
Mailing Address - Street 2:SUITE 1302
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-594-4949
Mailing Address - Fax:804-594-4948
Practice Address - Street 1:14051 SAINT FRANCIS BOULEVARD
Practice Address - Street 2:SUITE 1302
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114
Practice Address - Country:US
Practice Address - Phone:804-594-4949
Practice Address - Fax:804-594-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA246765OtherANTHEM BC BS
VA7147989OtherCIGNA HEALTHCARE
VA5824080001Medicare NSC