Provider Demographics
NPI:1508594490
Name:CHERRY BLOSSOM INTIMATES INC
Entity Type:Organization
Organization Name:CHERRY BLOSSOM INTIMATES INC
Other - Org Name:MYYA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-580-0059
Mailing Address - Street 1:PO BOX 7193
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20792-7193
Mailing Address - Country:US
Mailing Address - Phone:301-291-5013
Mailing Address - Fax:
Practice Address - Street 1:12150 ANNAPOLIS RD STE 309
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9183
Practice Address - Country:US
Practice Address - Phone:301-291-5013
Practice Address - Fax:240-245-7900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHERRY BLOSSOM INTIMATES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-10
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD333675000Medicaid