Provider Demographics
NPI:1851408595
Name:THE RE-CREATION BOUTIQUE INC.
Entity Type:Organization
Organization Name:THE RE-CREATION BOUTIQUE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:SCIACCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-746-0312
Mailing Address - Street 1:15253 10TH AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1216
Mailing Address - Country:US
Mailing Address - Phone:718-746-0213
Mailing Address - Fax:718-746-4696
Practice Address - Street 1:15253 10TH AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1216
Practice Address - Country:US
Practice Address - Phone:718-746-0213
Practice Address - Fax:718-746-4696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01481983Medicaid
NY0645140001Medicare NSC