Provider Demographics
NPI:1104829258
Name:AVAMERE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:AVAMERE MEDICAL SUPPLY LLC
Other - Org Name:SIGNATURE MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-224-2819
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:STE F
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:503-783-2483
Mailing Address - Fax:503-783-2480
Practice Address - Street 1:25117 SW PARKWAY AVE
Practice Address - Street 2:STE F
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:503-783-2483
Practice Address - Fax:503-783-2480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230869Medicaid
WA9052515Medicaid
AKMS001ORMedicaid
WA9052515Medicaid