Provider Demographics
NPI:1699356923
Name:ARIA LONDON BOUTIQUE
Entity type:Organization
Organization Name:ARIA LONDON BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATRESE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-250-4601
Mailing Address - Street 1:2311 GWENDALE DR E
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3524
Mailing Address - Country:US
Mailing Address - Phone:478-250-4601
Mailing Address - Fax:
Practice Address - Street 1:2311 GWENDALE DR E
Practice Address - Street 2:
Practice Address - City:LIZELLA
Practice Address - State:GA
Practice Address - Zip Code:31052-3524
Practice Address - Country:US
Practice Address - Phone:478-250-4601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier