Provider Demographics
NPI:1144965161
Name:ANJELIC BOUTIQUE
Entity type:Organization
Organization Name:ANJELIC BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELICA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-334-6216
Mailing Address - Street 1:923 APPLEGATE CIR
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-8856
Mailing Address - Country:US
Mailing Address - Phone:864-334-6216
Mailing Address - Fax:864-404-4824
Practice Address - Street 1:923 APPLEGATE CIR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-8856
Practice Address - Country:US
Practice Address - Phone:864-334-6216
Practice Address - Fax:864-404-4824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier