Organization
BRILLIANT MEDICAL BOUTIQUE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAMIE B MITTENDORF (OWNER)
(817) 594-5868
Entity
Organization
Contact information
Practice address
6800 HARRIS PKWY STE 300, FORT WORTH, TX 76132-4262
(682) 312-9300
(682) 312-9133
Mailing address
6800 HARRIS PKWY STE 300, FORT WORTH, TX 76132-4262
(682) 312-9300
(682) 312-9133
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
335E00000X
Prosthetic/Orthotic Supplier
CFM01117
TN
Other
Enumeration date
02/11/2008
Last updated
09/08/2022
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