1164717831 NPI number — AFFORDABLE MEDICAL & DENTAL SUPPLY LLC

Table of content: (NPI 1164717831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164717831 NPI number — AFFORDABLE MEDICAL & DENTAL SUPPLY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFFORDABLE MEDICAL & DENTAL SUPPLY 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:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1164717831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1680 DUNN AVE
Provider Second Line Business Mailing Address:
5
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32218-4782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-727-3016
Provider Business Mailing Address Fax Number:
888-522-5943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1680 DUNN AVE STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32218-4788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-727-3016
Provider Business Practice Location Address Fax Number:
888-522-5943
Provider Enumeration Date:
06/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
POLITE
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
DIRECTOR OF AMDS
Authorized Official Telephone Number:
888-727-3016

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2080154249098 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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