Provider Demographics
NPI:1235260647
Name:LDB MEDICAL, INC.
Entity Type:Organization
Organization Name:LDB MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:L.
Authorized Official - Middle Name:DERRYL
Authorized Official - Last Name:BREAZEALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-446-2554
Mailing Address - Street 1:2909 LANGFORD RD
Mailing Address - Street 2:STE B500
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2909 LANGFORD RD
Practice Address - Street 2:STE B500
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1590
Practice Address - Country:US
Practice Address - Phone:770-446-2554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0198170001Medicare ID - Type Unspecified