Provider Demographics
NPI:1093221798
Name:QUALITY OF LIFE DME LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:QUALITY OF LIFE DME LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-896-8686
Mailing Address - Street 1:1501 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-2008
Mailing Address - Country:US
Mailing Address - Phone:727-485-8780
Mailing Address - Fax:855-816-9860
Practice Address - Street 1:1501 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-2008
Practice Address - Country:US
Practice Address - Phone:727-485-8780
Practice Address - Fax:855-816-9860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6109332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56170300Medicaid