Provider Demographics
NPI:1407347586
Name:FUNCTIONAL DME
Entity Type:Organization
Organization Name:FUNCTIONAL DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-412-9955
Mailing Address - Street 1:PO BOX 1772
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70571-1772
Mailing Address - Country:US
Mailing Address - Phone:225-412-9955
Mailing Address - Fax:225-412-9957
Practice Address - Street 1:930B PRAYER HOUSE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:LA
Practice Address - Zip Code:70589-9113
Practice Address - Country:US
Practice Address - Phone:225-412-9955
Practice Address - Fax:225-412-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2494589Medicaid