Provider Demographics
NPI:1376759514
Name:MEDICOM, INC.
Entity Type:Organization
Organization Name:MEDICOM, INC.
Other - Org Name:LYON HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-774-6279
Mailing Address - Street 1:215 NORTH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2553
Mailing Address - Country:US
Mailing Address - Phone:573-774-8488
Mailing Address - Fax:573-774-6806
Practice Address - Street 1:215 NORTH ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2553
Practice Address - Country:US
Practice Address - Phone:573-774-8488
Practice Address - Fax:573-774-6806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO900708332B00000X, 332BX2000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0474100002Medicare ID - Type UnspecifiedMEDICARE NUMBER