Provider Demographics
NPI:1316047350
Name:LIFESHAPES BOUTIQUE INC
Entity type:Organization
Organization Name:LIFESHAPES BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:NORIEGA
Authorized Official - Last Name:DICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-629-6331
Mailing Address - Street 1:518 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4037
Mailing Address - Country:US
Mailing Address - Phone:813-654-6968
Mailing Address - Fax:813-655-6968
Practice Address - Street 1:518 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4037
Practice Address - Country:US
Practice Address - Phone:813-654-6968
Practice Address - Fax:813-655-6968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM2444OtherBCBS
FLM2444OtherBCBS