1184058281 NPI number — BOOMER MEDICAL 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 1184058281 NPI number — BOOMER MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOOMER MEDICAL 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:
1184058281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17935 E FLORIDA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80017-5315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-913-9425
Provider Business Mailing Address Fax Number:
720-282-3215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17935 EAST FLORIDA DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-913-9425
Provider Business Practice Location Address Fax Number:
720-282-3215
Provider Enumeration Date:
08/26/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CALISE
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
281-913-9425

Provider Taxonomy Codes

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

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