Provider Demographics
NPI:1174509350
Name:RED BALL MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:RED BALL MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:STORER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-424-8393
Mailing Address - Street 1:PO BOX 7623
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7623
Mailing Address - Country:US
Mailing Address - Phone:318-424-8393
Mailing Address - Fax:318-222-6104
Practice Address - Street 1:1020 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6747
Practice Address - Country:US
Practice Address - Phone:318-424-8393
Practice Address - Fax:318-222-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09-0007047332B00000X
LA4028332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1316792Medicaid
LA27623OtherBLUE CROSS
LA56735OtherNORTHWOOD
LA1316792Medicaid