Provider Demographics
NPI:1679296925
Name:DEMI'S LAVISHED BOUTIQUE LLC
Entity type:Organization
Organization Name:DEMI'S LAVISHED BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIC ORTHOTIC PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DEMITRIS
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:CARAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-541-3152
Mailing Address - Street 1:2601 WOODLAND PARK DR APT 1216
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-6163
Mailing Address - Country:US
Mailing Address - Phone:832-541-3152
Mailing Address - Fax:
Practice Address - Street 1:14020 S POST OAK RD STE 2103
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77045-5161
Practice Address - Country:US
Practice Address - Phone:832-541-3152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier