1013045806 NPI number — DIVERSIFIED MEDICAL DISTRIBUTION INC.

Table of content: (NPI 1013045806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013045806 NPI number — DIVERSIFIED MEDICAL DISTRIBUTION INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSIFIED MEDICAL DISTRIBUTION INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013045806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3035 E PATRICK LN
Provider Second Line Business Mailing Address:
STE # 1
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89120-4930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-660-0567
Provider Business Mailing Address Fax Number:
866-425-6020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3035 E PATRICK LN
Provider Second Line Business Practice Location Address:
STE # 1
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89120-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-660-0567
Provider Business Practice Location Address Fax Number:
866-425-6020
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RASTINEHAD
Authorized Official First Name:
RAMEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
800-348-6337

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  MP00275 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 192495 . This is a "STATE OF NV BUSINESS LIC" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 37533 . This is a "ACCREDITATION COMMISSION FOR HEALTH CARE, INC." identifier . This identifiers is of the category "OTHER".




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