Provider Demographics
NPI:1629138524
Name:INTIMATE BOUTIQUE 2, LTD
Entity Type:Organization
Organization Name:INTIMATE BOUTIQUE 2, LTD
Other - Org Name:BETTY SCHWARTZS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIORETTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-432-0220
Mailing Address - Street 1:1833 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035
Mailing Address - Country:US
Mailing Address - Phone:847-432-0220
Mailing Address - Fax:
Practice Address - Street 1:1833 SECOND STREET
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-432-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15359379335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0376280001Medicare NSC