# BRILLIANT MEDICAL BOUTIQUE LLC

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

## Provider details

- **NPI number:** 1497793830
- **Authorized official:** JAMIE B. MITTENDORF (OWNER AND OPERATOR)
- **Authorized official phone:** (817) 594-5868

## Contact information

- **Practice address:** 925 SANTA FE DR, SUITE 100, WEATHERFORD, TX 76086-5866
- **Practice address phone:** (817) 594-5868
- **Practice address fax:** (817) 594-5833
- **Mailing address:** 925 SANTA FE DR, SUITE 100, WEATHERFORD, TX 76086-5866
- **Mailing address phone:** (817) 594-5868
- **Mailing address fax:** (817) 594-5833

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | Yes |
| 335E00000X | Prosthetic/Orthotic Supplier | — | NULL | — |

## Other

- **Enumeration date:** 06/04/2006
- **Last updated:** 09/08/2022