Provider Demographics
NPI:1093932485
Name:MEDICAL 1 PATIENT SERVICES
Entity Type:Organization
Organization Name:MEDICAL 1 PATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-906-0651
Mailing Address - Street 1:3310 WOODCREST DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-2500
Mailing Address - Country:US
Mailing Address - Phone:225-906-0651
Mailing Address - Fax:225-927-1528
Practice Address - Street 1:3310 WOODCREST DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70814-2500
Practice Address - Country:US
Practice Address - Phone:225-906-0651
Practice Address - Fax:225-927-1528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1000865780332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5934880001Medicare NSC