Provider Demographics
NPI:1255323671
Name:ROOSTER MEDICAL EQUIPMENT & SUPPLIES
Entity Type:Organization
Organization Name:ROOSTER MEDICAL EQUIPMENT & SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:B J
Authorized Official - Middle Name:
Authorized Official - Last Name:EKANEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-923-1900
Mailing Address - Street 1:3000 SANDAGE AVE
Mailing Address - Street 2:109
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-1768
Mailing Address - Country:US
Mailing Address - Phone:817-923-1900
Mailing Address - Fax:817-923-1952
Practice Address - Street 1:3000 SANDAGE AVE
Practice Address - Street 2:109
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1768
Practice Address - Country:US
Practice Address - Phone:817-923-1900
Practice Address - Fax:817-923-1952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0060761332B00000X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX531195OtherBLUE CROSS/BLUE SHIELD
TX1513520102Medicaid
TX4482600001Medicare ID - Type Unspecified