1083608855 NPI number — SENIOR CARE MEDICAL SUPPLY, INC.

Table of content: (NPI 1083608855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083608855 NPI number — SENIOR CARE MEDICAL SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIOR CARE MEDICAL SUPPLY, 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:
1083608855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 473
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKMULGEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74447-0473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-756-1749
Provider Business Mailing Address Fax Number:
918-756-1754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 E 20TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKMULGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74447-6029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-756-1749
Provider Business Practice Location Address Fax Number:
918-756-1754
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STUDDARD
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
918-756-1749

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: 100811500 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 731435468-001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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