Provider Demographics
NPI:1851635031
Name:SECOND TO NATURE BOUTIQUE, LLC
Entity Type:Organization
Organization Name:SECOND TO NATURE BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:R
Authorized Official - Last Name:HERTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:336-274-2003
Mailing Address - Street 1:500 STATE ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5659
Mailing Address - Country:US
Mailing Address - Phone:336-274-2003
Mailing Address - Fax:
Practice Address - Street 1:2549 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-0676
Practice Address - Country:US
Practice Address - Phone:276-670-2727
Practice Address - Fax:276-670-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10--F001335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier