Provider Demographics
NPI:1417160441
Name:PROMINENT HEALTH SUPPLIES
Entity Type:Organization
Organization Name:PROMINENT HEALTH SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-987-1466
Mailing Address - Street 1:2744 HONEY SUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8557
Mailing Address - Country:US
Mailing Address - Phone:817-269-5538
Mailing Address - Fax:
Practice Address - Street 1:2744 HONEY SUCKLE DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8557
Practice Address - Country:US
Practice Address - Phone:817-269-5538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies