Provider Demographics
NPI:1760630644
Name:GIRLFRIENDS, LLC
Entity Type:Organization
Organization Name:GIRLFRIENDS, LLC
Other - Org Name:GIRLFRIENDS...THE BRA SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GLASCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS ED
Authorized Official - Phone:815-780-8151
Mailing Address - Street 1:4419 PROGRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1109
Mailing Address - Country:US
Mailing Address - Phone:815-780-8151
Mailing Address - Fax:815-780-8151
Practice Address - Street 1:4419 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1109
Practice Address - Country:US
Practice Address - Phone:815-780-8151
Practice Address - Fax:815-780-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6394900001Medicare NSC