Provider Demographics
NPI:1417154618
Name:PRESTIGIOUS MEDICAL SUPPLY
Entity Type:Organization
Organization Name:PRESTIGIOUS MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-422-1447
Mailing Address - Street 1:7480 W. 38TH AVE.
Mailing Address - Street 2:
Mailing Address - City:WHEATRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4845
Mailing Address - Country:US
Mailing Address - Phone:303-422-1447
Mailing Address - Fax:303-422-3019
Practice Address - Street 1:7470 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4845
Practice Address - Country:US
Practice Address - Phone:303-422-1447
Practice Address - Fax:303-422-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33306338Medicaid