Organization
ROBERTAS LOVELY LADIES BOUTIQUE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ROBERTA J JAYNES (OWNER SOLE PROPIETOR)
(618) 467-0640
Entity
Organization
Contact information
Practice address
603 WEST DELMAR, ALTON, IL 62002
(618) 467-0640
(618) 467-8819
Mailing address
603 WEST DELMAR, ALTON, IL 62002
(618) 467-0640
(618) 467-8819
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
A1735
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06020694
BCBS OF IL
IL
01
—
137024
BCBS OF MO
IL
01
—
2375728
AETNA
IL
01
—
269893
HEALTHLINK OF IL
—
01
—
5824316
AETNA
IL
01
—
BA7549138
MULTI PLAN OF IL
IL
01
—
L038503
TRICARE
—
Enumeration date
04/20/2006
Last updated
06/18/2015
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