Provider Demographics
NPI:1225499080
Name:BOHANNAN MEDICAL DIST., LLC
Entity Type:Organization
Organization Name:BOHANNAN MEDICAL DIST., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-678-8081
Mailing Address - Street 1:11417 N BOULDER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-1500
Mailing Address - Country:US
Mailing Address - Phone:309-678-8081
Mailing Address - Fax:
Practice Address - Street 1:11417 N BOULDER CREEK CT
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-1500
Practice Address - Country:US
Practice Address - Phone:309-678-8081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies