1679570121 NPI number — INNOVATIVE MEDICAL SUPPLY, LLC

Table of content: (NPI 1679570121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679570121 NPI number — INNOVATIVE MEDICAL SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE MEDICAL 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:
IMED SUPPLY
Provider Other Organization Name Type Code:
3
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:
1679570121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 SE 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73160-8231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-799-8855
Provider Business Mailing Address Fax Number:
405-799-8860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 SE 4TH ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MOORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73160-8231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-799-8855
Provider Business Practice Location Address Fax Number:
405-799-8860
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
405-799-8855

Provider Taxonomy Codes

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

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

  • Identifier: 2023000A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 209078400 . This is a "DEPT OF LABOR PROVIDER #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 20536475001 . This is a "TRICARE PROVIDER NUMBER" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com