Provider Demographics
NPI:1639570559
Name:LE BUSTIERE BOUTIQUE LLC
Entity Type:Organization
Organization Name:LE BUSTIERE BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-745-8080
Mailing Address - Street 1:1744 COLUMBIA RD NW
Mailing Address - Street 2:#2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-2881
Mailing Address - Country:US
Mailing Address - Phone:202-745-8080
Mailing Address - Fax:202-745-8081
Practice Address - Street 1:1744 COLUMBIA RD NW
Practice Address - Street 2:#2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-2881
Practice Address - Country:US
Practice Address - Phone:202-745-8080
Practice Address - Fax:202-745-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC400314900285332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier