Provider Demographics
NPI:1245698984
Name:AT LAST BRA AND LINGERIE BOUTIQUE LLC
Entity type:Organization
Organization Name:AT LAST BRA AND LINGERIE BOUTIQUE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENITA
Authorized Official - Middle Name:LEICHELLE
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:916-480-9501
Mailing Address - Street 1:1329 HOWE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3363
Mailing Address - Country:US
Mailing Address - Phone:916-480-9501
Mailing Address - Fax:916-514-8991
Practice Address - Street 1:1329 HOWE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3363
Practice Address - Country:US
Practice Address - Phone:916-480-9501
Practice Address - Fax:916-800-8271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52184335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier