Provider Demographics
NPI:1396824801
Name:TEXAS MEDICAL SUPPLIES AND REHABILITATION NETWORK
Entity Type:Organization
Organization Name:TEXAS MEDICAL SUPPLIES AND REHABILITATION NETWORK
Other - Org Name:TX MEDICAL SUPPLIES & REHAB NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:FOMUKONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-272-5820
Mailing Address - Street 1:2433 GOLDFINCH LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-8022
Mailing Address - Country:US
Mailing Address - Phone:972-272-5820
Mailing Address - Fax:972-272-5820
Practice Address - Street 1:2433 GOLDFINCH LN
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-8022
Practice Address - Country:US
Practice Address - Phone:972-272-5820
Practice Address - Fax:972-272-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0080220332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1734238Medicaid
TX1734238Medicaid