| Organization Name: | ROBERTAS LOVELY LADIES BOUTIQUE |
| NPI Number: | 1376508309 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ROBERTA J JAYNES (OWNER SOLE PROPIETOR) |
| Mailing Address: | 603 West Delmar Alton |
| State: | IL US |
| Postal Code: | 62002 |
| Phone Number: | 6184670640 |
| Fax Number: | 6184678819 |
| NPI Enumeration Date: | 04/20/2006 |
| NPI Last Update Date: | 06/18/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | A1735 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |