Provider Demographics
NPI:1053745299
Name:COCO'S LINGERIE BOUTIQUE
Entity type:Organization
Organization Name:COCO'S LINGERIE BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTHIAUME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-561-8185
Mailing Address - Street 1:35 KAINEHE ST
Mailing Address - Street 2:#102
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-6127
Mailing Address - Country:US
Mailing Address - Phone:808-262-6752
Mailing Address - Fax:
Practice Address - Street 1:35 KAINEHE ST
Practice Address - Street 2:#102
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-6127
Practice Address - Country:US
Practice Address - Phone:808-262-6752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIW59039495-01332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies