Provider Demographics
NPI:1104828409
Name:VANTAGE DME
Entity Type:Organization
Organization Name:VANTAGE DME
Other - Org Name:VANTAGE HOME RESPIRATORY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRTT
Authorized Official - Phone:813-333-9449
Mailing Address - Street 1:3 ORTHOPAEDIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125
Mailing Address - Country:US
Mailing Address - Phone:724-589-5540
Mailing Address - Fax:724-589-5543
Practice Address - Street 1:3 ORTHOPAEDIC DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125
Practice Address - Country:US
Practice Address - Phone:724-589-5540
Practice Address - Fax:724-589-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1103530003Medicare ID - Type Unspecified