Provider Demographics
NPI:1427004944
Name:SOUTHLAKE MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:SOUTHLAKE MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:COZZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-319-8090
Mailing Address - Street 1:2140 E. SOUTHLAKE BLVD.
Mailing Address - Street 2:#L-675
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6516
Mailing Address - Country:US
Mailing Address - Phone:817-319-8090
Mailing Address - Fax:
Practice Address - Street 1:2140 E. SOUTHLAKE BLVD.
Practice Address - Street 2:#L-675
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6516
Practice Address - Country:US
Practice Address - Phone:817-319-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0054467332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143425002Medicaid
TX143425001Medicaid
TX143425002Medicaid
TX143425002Medicaid