Provider Demographics
NPI:1497793830
Name:BRILLIANT MEDICAL BOUTIQUE LLC
Entity type:Organization
Organization Name:BRILLIANT MEDICAL BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MITTENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-594-5868
Mailing Address - Street 1:925 SANTA FE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5866
Mailing Address - Country:US
Mailing Address - Phone:817-594-5868
Mailing Address - Fax:817-594-5833
Practice Address - Street 1:925 SANTA FE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5866
Practice Address - Country:US
Practice Address - Phone:817-594-5868
Practice Address - Fax:817-594-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178601402Medicaid
TX5619870001Medicare NSC