Provider Demographics
NPI:1588996946
Name:SOPHISTICATED LADY BOUTIQUE
Entity type:Organization
Organization Name:SOPHISTICATED LADY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:EPPERLY
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:828-837-2790
Mailing Address - Street 1:26 VALLEY RIVER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:NC
Mailing Address - Zip Code:28906-2955
Mailing Address - Country:US
Mailing Address - Phone:828-837-2790
Mailing Address - Fax:828-837-2790
Practice Address - Street 1:26 VALLEY RIVER AVE STE B
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-2955
Practice Address - Country:US
Practice Address - Phone:828-837-2790
Practice Address - Fax:828-837-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6041840001Medicare NSC