Provider Demographics
NPI:1346577715
Name:ETAIL MEDICAL LLC
Entity Type:Organization
Organization Name:ETAIL MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DEZENGREMEL
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:303-884-1935
Mailing Address - Street 1:5156 RIALTO DR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-5234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:303-379-3775
Practice Address - Street 1:5156 RIALTO DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-5234
Practice Address - Country:US
Practice Address - Phone:303-667-5929
Practice Address - Fax:303-379-3775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20091385108332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies