Provider Demographics
NPI:1144059437
Name:MAGIQUE BOUTIQUE LLC
Entity type:Organization
Organization Name:MAGIQUE BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-230-5780
Mailing Address - Street 1:760 WHALERS WAY STE C120
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3372
Mailing Address - Country:US
Mailing Address - Phone:970-230-5780
Mailing Address - Fax:970-236-2596
Practice Address - Street 1:760 WHALERS WAY STE C120
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3372
Practice Address - Country:US
Practice Address - Phone:970-230-5780
Practice Address - Fax:970-236-2596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies