Provider Demographics
NPI:1033343603
Name:BLACKWATER MEDICAL LLC
Entity Type:Organization
Organization Name:BLACKWATER MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-264-0059
Mailing Address - Street 1:1 LINCOLN PKWY
Mailing Address - Street 2:SUITE #305
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3262
Mailing Address - Country:US
Mailing Address - Phone:601-264-0059
Mailing Address - Fax:866-691-3186
Practice Address - Street 1:1 LINCOLN PKWY
Practice Address - Street 2:SUITE #305
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3262
Practice Address - Country:US
Practice Address - Phone:601-264-0059
Practice Address - Fax:866-691-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies