1760786776 NPI number — MEDI QUIP SUPPLY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760786776 NPI number — MEDI QUIP SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDI QUIP SUPPLY
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:
1760786776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5057 HWY 42 E.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-310-4499
Provider Business Mailing Address Fax Number:
601-544-8404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5057 HWY 42 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-310-4499
Provider Business Practice Location Address Fax Number:
601-544-8404
Provider Enumeration Date:
01/05/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TOMLIN
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
EVERITTE
Authorized Official Title or Position:
OWNER (SOLE MEMBER)
Authorized Official Telephone Number:
601-310-4499

Provider Taxonomy Codes

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

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