1528091774 NPI number — FOUR CORNERS MEDICAL SUPPLY

Table of content: (NPI 1528091774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528091774 NPI number — FOUR CORNERS MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR CORNERS 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:
1528091774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1050 US HIGHWAY 27
Provider Second Line Business Mailing Address:
SUITE 20
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34714-7508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 US HIGHWAY 27
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34714-7508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-243-7477
Provider Business Practice Location Address Fax Number:
352-243-7877
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MENDOZA
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-243-7477

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 3204596 . This is a "MEDICAL OXYGEN RETAILER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1312914 . This is a "AHCA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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