Provider Demographics
NPI:1447431879
Name:THE BRA LADY BOUTIQUE, INC
Entity type:Organization
Organization Name:THE BRA LADY BOUTIQUE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LUMPKIN
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED MASTECTOMY
Authorized Official - Phone:434-793-5239
Mailing Address - Street 1:1085 PINEY FOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-1507
Mailing Address - Country:US
Mailing Address - Phone:434-793-5239
Mailing Address - Fax:434-793-5240
Practice Address - Street 1:1085 PINEY FOREST ROAD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-1507
Practice Address - Country:US
Practice Address - Phone:434-793-5239
Practice Address - Fax:434-793-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009190236Medicaid
VA217268OtherBC/BS OF VA
VA217268OtherANTHEM/BLUE CROSS
VA217268OtherANTHEM/BLUE CROSS
VA1299060001Medicare NSC