# BRILLIANT MEDICAL BOUTIQUE, LLC

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

## Provider details

- **NPI number:** 1770751950
- **Authorized official:** JAMIE B MITTENDORF (OWNER)
- **Authorized official phone:** (817) 594-5868

## Contact information

- **Practice address:** 6800 HARRIS PKWY STE 300, FORT WORTH, TX 76132-4262
- **Practice address phone:** (682) 312-9300
- **Practice address fax:** (682) 312-9133
- **Mailing address:** 6800 HARRIS PKWY STE 300, FORT WORTH, TX 76132-4262
- **Mailing address phone:** (682) 312-9300
- **Mailing address fax:** (682) 312-9133

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | Yes |
| 335E00000X | Prosthetic/Orthotic Supplier | CFM01117 | TN | — |

## Other

- **Enumeration date:** 02/11/2008
- **Last updated:** 09/08/2022