Provider Demographics
NPI:1366694622
Name:CRESTVIEW MEDICAL EQUIPMENT SUPPLY LLC
Entity Type:Organization
Organization Name:CRESTVIEW MEDICAL EQUIPMENT SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUMUYIWA
Authorized Official - Middle Name:
Authorized Official - Last Name:AKINYODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-853-7422
Mailing Address - Street 1:2100 S GREAT SOUTHWEST PKWY
Mailing Address - Street 2:STE 103
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3543
Mailing Address - Country:US
Mailing Address - Phone:972-853-7422
Mailing Address - Fax:
Practice Address - Street 1:2100 S GREAT SOUTHWEST PKWY
Practice Address - Street 2:STE 103
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3543
Practice Address - Country:US
Practice Address - Phone:972-853-7422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211490201Medicaid
TX211490202Medicaid
TX211490201Medicaid