Provider Demographics
NPI:1073585451
Name:EBONY MEDICAL EQUIPMENT & SUPPLIES , INC
Entity Type:Organization
Organization Name:EBONY MEDICAL EQUIPMENT & SUPPLIES , INC
Other - Org Name:EBONY MEDICAL EQUIPMENT & SUPPLIES , INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICODEMUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:UDOFIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-593-1264
Mailing Address - Street 1:427 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5502
Mailing Address - Country:US
Mailing Address - Phone:903-593-1264
Mailing Address - Fax:903-533-0156
Practice Address - Street 1:427 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5502
Practice Address - Country:US
Practice Address - Phone:903-593-1264
Practice Address - Fax:903-533-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0056126332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148551802Medicaid
TX4302010001Medicare NSC