Provider Demographics
NPI:1033360490
Name:PROVIDACARE MEDICAL SUPPLY LTD
Entity Type:Organization
Organization Name:PROVIDACARE MEDICAL SUPPLY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-733-6518
Mailing Address - Street 1:3721 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1645
Mailing Address - Country:US
Mailing Address - Phone:512-733-6518
Mailing Address - Fax:512-795-9185
Practice Address - Street 1:1300 HWY 281
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4504
Practice Address - Country:US
Practice Address - Phone:830-693-7313
Practice Address - Fax:830-693-7363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5653740004Medicare NSC