Provider Demographics
NPI:1487028296
Name:RENEW THE BREAST CARE BOUTIQUE INC
Entity Type:Organization
Organization Name:RENEW THE BREAST CARE BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-876-4022
Mailing Address - Street 1:5601 OKEECHOBEE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-4489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 OKEECHOBEE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33417-4489
Practice Address - Country:US
Practice Address - Phone:561-328-7434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment