1043339187 NPI number — SOUTH MEDICAL SUPPLY AND EQUIPMENT LLC

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 1043339187 NPI number — SOUTH MEDICAL SUPPLY AND EQUIPMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH MEDICAL SUPPLY AND EQUIPMENT LLC
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:
1043339187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6523B DUCK CREEK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-303-7602
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6523 DUCK CREEK DR # B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75043-3644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-303-7602
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ISIDAEHOMEN
Authorized Official First Name:
LOVETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-303-7602

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  0062174 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 155295001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 155295202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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