Provider Demographics
NPI:1073755542
Name:MEDI-VATION
Entity Type:Organization
Organization Name:MEDI-VATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-316-6958
Mailing Address - Street 1:10 BONNE TERRE BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6921
Mailing Address - Country:US
Mailing Address - Phone:601-316-6958
Mailing Address - Fax:601-925-4950
Practice Address - Street 1:10 BONNE TERRE BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6921
Practice Address - Country:US
Practice Address - Phone:601-316-6958
Practice Address - Fax:601-925-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies