Provider Demographics
NPI:1124043534
Name:HOSPICE SUPPLY INC
Entity Type:Organization
Organization Name:HOSPICE SUPPLY INC
Other - Org Name:LAKEWAY HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-693-5303
Mailing Address - Street 1:1905 COLONIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3117
Mailing Address - Country:US
Mailing Address - Phone:575-693-2665
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKEWAY DR STE 2
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4467
Practice Address - Country:US
Practice Address - Phone:512-263-5676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5603910001Medicare NSC