Organization
BRILLIANT MEDICAL BOUTIQUE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAMIE B. MITTENDORF (OWNER AND OPERATOR)
(817) 594-5868
Entity
Organization
Contact information
Practice address
925 SANTA FE DR, SUITE 100, WEATHERFORD, TX 76086-5866
(817) 594-5868
(817) 594-5833
Mailing address
925 SANTA FE DR, SUITE 100, WEATHERFORD, TX 76086-5866
(817) 594-5868
(817) 594-5833
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
335E00000X
Prosthetic/Orthotic Supplier
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
178601402
—
TX
Enumeration date
06/04/2006
Last updated
09/08/2022
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