Brilliant Medical Boutique LLC

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

Legal business name

BRILLIANT MEDICAL BOUTIQUE LLC

Practice address

925 Santa Fe Dr
Suite 100
Weatherford, TX 76086-5866

Phone

(817) 594-5868

Fax

(817) 594-5833

NPI assigned

Jun 4, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jamie B. Mittendorf

Title

Owner and Operator

Phone

(817) 594-5868

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Brilliant Medical Boutique, LLC

  • Durable Medical Equipment & Medical Supplies
  • Fort Worth, TX
  • NPI 1770751950

  1254533656

  Same PAC ID

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Tax ID family

Brilliant Medical Boutique LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Brilliant Medical Boutique, LLC

  • Durable Medical Equipment & Medical Supplies
  • Fort Worth, TX
  • NPI 1770751950
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149379200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1662595200000",
    "number": "1497793830",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "925 SANTA FE DR",
            "address_2": "SUITE 100",
            "city": "WEATHERFORD",
            "state": "TX",
            "postal_code": "760865866",
            "telephone_number": "817-594-5868",
            "fax_number": "817-594-5833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "925 SANTA FE DR",
            "address_2": "SUITE 100",
            "city": "WEATHERFORD",
            "state": "TX",
            "postal_code": "760865866",
            "telephone_number": "817-594-5868",
            "fax_number": "817-594-5833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRILLIANT MEDICAL BOUTIQUE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-04",
        "last_updated": "2022-09-08",
        "certification_date": "2022-09-08",
        "status": "A",
        "authorized_official_last_name": "MITTENDORF",
        "authorized_official_first_name": "JAMIE",
        "authorized_official_middle_name": "B.",
        "authorized_official_title_or_position": "OWNER AND OPERATOR",
        "authorized_official_telephone_number": "817-594-5868"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "178601402",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Angelia G Breeze, LMT
• Jennifer Breito, CRNA
• Lindsey Brewer
• Brian Westfall DDS PA
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• Brian Brinkmann
• Brittany Briswalter, M.S, LPC
• Brock Independent School District
• Brookdale Senior Living Communities, Inc.
• Andrea Curry Brooks

• All providers in Weatherford, TX
• Durable Medical Equipment & Medical Supplies in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.