Provider Demographics
NPI:1720657406
Name:BETTY JEANS LLC
Entity type:Organization
Organization Name:BETTY JEANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:QUINNCHEL
Authorized Official - Middle Name:PREEON
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-502-9733
Mailing Address - Street 1:10615 GRETA LYNN CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7748
Mailing Address - Country:US
Mailing Address - Phone:804-502-9733
Mailing Address - Fax:
Practice Address - Street 1:10615 GRETA LYNN CT
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-7748
Practice Address - Country:US
Practice Address - Phone:804-502-9733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date: