Provider Demographics
NPI:1154045888
Name:BIRCH BOUTIQUE LLC
Entity type:Organization
Organization Name:BIRCH BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMANY
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CMF
Authorized Official - Phone:715-350-7174
Mailing Address - Street 1:612 CLEMONT ST
Mailing Address - Street 2:STE #8
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-1988
Mailing Address - Country:US
Mailing Address - Phone:715-350-7174
Mailing Address - Fax:715-716-4330
Practice Address - Street 1:612 CLEMONT ST
Practice Address - Street 2:STE #8
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-1988
Practice Address - Country:US
Practice Address - Phone:715-350-7174
Practice Address - Fax:715-716-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-27
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty