Provider Demographics
NPI:1407937121
Name:QUAD STATES MEDICAL REHAB AND SUPPLY LLC
Entity Type:Organization
Organization Name:QUAD STATES MEDICAL REHAB AND SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:50 SHAREHOLDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-646-2886
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:MO
Mailing Address - Zip Code:64776-0564
Mailing Address - Country:US
Mailing Address - Phone:417-646-2886
Mailing Address - Fax:660-885-2640
Practice Address - Street 1:107 WESMOR ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1786
Practice Address - Country:US
Practice Address - Phone:417-646-2886
Practice Address - Fax:660-885-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO19368569332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5623120001Medicare NSC