Provider Demographics
NPI:1740553759
Name:A MOTHER'S BOUTIQUE, LLC
Entity type:Organization
Organization Name:A MOTHER'S BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MASUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:724-934-8795
Mailing Address - Street 1:145 LAKE DR STE 102R
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8473
Mailing Address - Country:US
Mailing Address - Phone:724-934-8795
Mailing Address - Fax:724-965-4085
Practice Address - Street 1:145 LAKE DR STE 102R
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8473
Practice Address - Country:US
Practice Address - Phone:724-934-8795
Practice Address - Fax:724-965-4085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA84060346332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies