1497793830 NPI number — BRILLIANT MEDICAL BOUTIQUE LLC

Table of content: (NPI 1497793830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497793830 NPI number — BRILLIANT MEDICAL BOUTIQUE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRILLIANT MEDICAL BOUTIQUE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497793830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 SANTA FE DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
WEATHERFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76086-5866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-594-5868
Provider Business Mailing Address Fax Number:
817-594-5833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 SANTA FE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WEATHERFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76086-5866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-594-5868
Provider Business Practice Location Address Fax Number:
817-594-5833
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITTENDORF
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER AND OPERATOR
Authorized Official Telephone Number:
817-594-5868

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 178601402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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