Provider Demographics
NPI:1053497008
Name:STRACON
Entity Type:Organization
Organization Name:STRACON
Other - Org Name:STRACON MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:ADESULU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-262-5053
Mailing Address - Street 1:810 DALWORTH ST STE B
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-5516
Mailing Address - Country:US
Mailing Address - Phone:972-262-5053
Mailing Address - Fax:972-262-7160
Practice Address - Street 1:810 DALWORTH ST STE B
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5516
Practice Address - Country:US
Practice Address - Phone:972-262-5053
Practice Address - Fax:972-262-7160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0085290332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179685602Medicaid
TX179685601Medicaid
TX5595140001Medicare NSC