Provider Demographics
NPI:1720159452
Name:STACEY'S BRA AND LINGERIE SHOP, INC
Entity type:Organization
Organization Name:STACEY'S BRA AND LINGERIE SHOP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BURNS-FOX
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:515-270-1399
Mailing Address - Street 1:10453 HICKMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322
Mailing Address - Country:US
Mailing Address - Phone:515-270-1399
Mailing Address - Fax:
Practice Address - Street 1:10453 HICKMAN ROAD
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-5032
Practice Address - Country:US
Practice Address - Phone:515-226-9336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0102509Medicaid
IA0674210001Medicare NSC
IA0102509Medicaid