Provider Demographics
NPI:1346531852
Name:DERIDDER MEDICAL EQUIPMENT SUPPLY
Entity Type:Organization
Organization Name:DERIDDER MEDICAL EQUIPMENT SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENTON
Authorized Official - Middle Name:RUDOLPH
Authorized Official - Last Name:BLAKENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-463-5291
Mailing Address - Street 1:2661 RUSS ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-6035
Mailing Address - Country:US
Mailing Address - Phone:337-463-5291
Mailing Address - Fax:337-463-5368
Practice Address - Street 1:709 MAHLON ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4221
Practice Address - Country:US
Practice Address - Phone:337-202-1911
Practice Address - Fax:337-202-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies