Provider Demographics
NPI:1568106573
Name:LOVE STRUCK VIRGIN REMY LLC
Entity Type:Organization
Organization Name:LOVE STRUCK VIRGIN REMY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:COTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-574-8970
Mailing Address - Street 1:261 N LAMB BLVD UNIT B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-0505
Mailing Address - Country:US
Mailing Address - Phone:314-574-8970
Mailing Address - Fax:
Practice Address - Street 1:261 N LAMB BLVD UNIT B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-0505
Practice Address - Country:US
Practice Address - Phone:314-574-8970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier