Provider Demographics
NPI:1518392430
Name:MODERN MOMMY BOUTIQUE
Entity Type:Organization
Organization Name:MODERN MOMMY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TALISHA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:HEIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-857-7187
Mailing Address - Street 1:3355 W CHANDLER BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5096
Mailing Address - Country:US
Mailing Address - Phone:480-857-7187
Mailing Address - Fax:
Practice Address - Street 1:3355 W CHANDLER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5096
Practice Address - Country:US
Practice Address - Phone:480-857-7187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies