Provider Demographics
NPI:1023395381
Name:PROVIDA MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:PROVIDA MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TROYAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-918-8085
Mailing Address - Street 1:1117 S MILWAUKEE AVE
Mailing Address - Street 2:D-5
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5257
Mailing Address - Country:US
Mailing Address - Phone:847-918-8085
Mailing Address - Fax:847-573-0223
Practice Address - Street 1:1117 S MILWAUKEE AVE
Practice Address - Street 2:SUITE D 5
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5257
Practice Address - Country:US
Practice Address - Phone:847-918-8085
Practice Address - Fax:847-573-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203001360332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203001360OtherLICENSE