Provider Demographics
NPI:1922105899
Name:YOUR IMAGE BOUTIQUE INC
Entity Type:Organization
Organization Name:YOUR IMAGE BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:915-564-5923
Mailing Address - Street 1:3401 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-4330
Mailing Address - Country:US
Mailing Address - Phone:915-564-5923
Mailing Address - Fax:915-565-1310
Practice Address - Street 1:3401 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4330
Practice Address - Country:US
Practice Address - Phone:915-564-5923
Practice Address - Fax:915-565-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010688201Medicaid
TX010688201Medicaid