Provider Demographics
NPI:1558760611
Name:A BEAUTIFUL YOU MASTECTOMY BOUTIQUE
Entity Type:Organization
Organization Name:A BEAUTIFUL YOU MASTECTOMY BOUTIQUE
Other - Org Name:A BEAUTIFUL YOU MASTECTOMY BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOVICK
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:208-985-5404
Mailing Address - Street 1:2006 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4343
Mailing Address - Country:US
Mailing Address - Phone:208-985-5404
Mailing Address - Fax:
Practice Address - Street 1:2006 BLAINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4343
Practice Address - Country:US
Practice Address - Phone:208-985-5404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCFM02746335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
224900000XOtherIRS