Provider Demographics
NPI:1629354279
Name:LAVENDER & LACE LINGERIE LLC
Entity Type:Organization
Organization Name:LAVENDER & LACE LINGERIE LLC
Other - Org Name:PINK RIBBON BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARB
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN TOLINGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-282-4679
Mailing Address - Street 1:8801 THREE CHOPT RD STE M
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4755
Mailing Address - Country:US
Mailing Address - Phone:804-282-4679
Mailing Address - Fax:804-288-4020
Practice Address - Street 1:8801 THREE CHOPT RD STE M
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-4755
Practice Address - Country:US
Practice Address - Phone:804-282-4679
Practice Address - Fax:804-288-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 335E00000X
VA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6784730001Medicare NSC