Provider Demographics
NPI:1386793438
Name:JENE'S LTD BOUTIQUE
Entity type:Organization
Organization Name:JENE'S LTD BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT (OWNER)
Authorized Official - Prefix:
Authorized Official - First Name:EUVIVA
Authorized Official - Middle Name:JENE
Authorized Official - Last Name:ALCARAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-694-7720
Mailing Address - Street 1:P.O. BOX 2545
Mailing Address - Street 2:312 ILLINI DRIVE
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611
Mailing Address - Country:US
Mailing Address - Phone:309-694-7720
Mailing Address - Fax:309-694-7748
Practice Address - Street 1:4700 N. UNIVERSITY
Practice Address - Street 2:SPC 93 METRO CENTER
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5849
Practice Address - Country:US
Practice Address - Phone:309-694-7720
Practice Address - Fax:309-694-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
ILC36319332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5343560001Medicare NSC
IL5343560001Medicare ID - Type Unspecified