Provider Demographics
NPI:1396042552
Name:CLUB MED LLC
Entity Type:Organization
Organization Name:CLUB MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DME SUPPLYER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-554-8850
Mailing Address - Street 1:7259 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1620
Mailing Address - Country:US
Mailing Address - Phone:888-554-8850
Mailing Address - Fax:877-829-6012
Practice Address - Street 1:7259 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1620
Practice Address - Country:US
Practice Address - Phone:888-554-8850
Practice Address - Fax:877-829-6012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies