Provider Demographics
NPI:1811059272
Name:NEW IMAGES BOUTIQUE CO INC
Entity type:Organization
Organization Name:NEW IMAGES BOUTIQUE CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:501-321-0552
Mailing Address - Street 1:222 CORNERSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6564
Mailing Address - Country:US
Mailing Address - Phone:501-321-0552
Mailing Address - Fax:501-520-0255
Practice Address - Street 1:222 CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6564
Practice Address - Country:US
Practice Address - Phone:501-321-0552
Practice Address - Fax:501-321-0849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48580OtherBLUE CROSS BLUE SHIELD
AR123073716Medicaid
AR48580OtherBLUE CROSS BLUE SHIELD
0505640001Medicare NSC