# ROBERTA'S LOVELY LADIES BOUTIQUE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174983050
- **Authorized official:** MRS. CAROL A LOGAN (OWNER)
- **Authorized official phone:** (618) 467-0095

## Contact information

- **Practice address:** 603 W. DELMAR, ALTON, IL 62002
- **Practice address phone:** (618) 467-0640
- **Mailing address:** 603 W. DELMAR, ALTON, IL 62002
- **Mailing address phone:** (618) 467-0640

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 224900000X | Mastectomy Fitter | — | NULL | Yes |
| 224900000X | Mastectomy Fitter | — | — | Yes |

## Other

- **Enumeration date:** 03/04/2016
- **Last updated:** 03/04/2016