Provider Demographics
NPI:1235282294
Name:DICKSON KUTEY
Entity Type:Organization
Organization Name:DICKSON KUTEY
Other - Org Name:MERITZ MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DICKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-641-1612
Mailing Address - Street 1:2100 N HIGHWAY 360
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1009
Mailing Address - Country:US
Mailing Address - Phone:972-641-1612
Mailing Address - Fax:972-641-1614
Practice Address - Street 1:2100 N HIGHWAY 360
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1009
Practice Address - Country:US
Practice Address - Phone:972-641-1612
Practice Address - Fax:972-641-1614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0068612332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172908901Medicaid
TX172908902Medicaid
TX172908902Medicaid