Provider Demographics
NPI:1770760654
Name:BETTY'S BOUTIQUE
Entity type:Organization
Organization Name:BETTY'S BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-525-7412
Mailing Address - Street 1:414 OVERHILL RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37914-4328
Mailing Address - Country:US
Mailing Address - Phone:865-525-7412
Mailing Address - Fax:865-525-7412
Practice Address - Street 1:414 OVERHILL RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37914-4328
Practice Address - Country:US
Practice Address - Phone:865-525-7412
Practice Address - Fax:865-525-7412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4420370001Medicare NSC