Provider Demographics
NPI:1467532697
Name:ST AUGUSTINE MEDICAL EQUIPMENT LLC
Entity Type:Organization
Organization Name:ST AUGUSTINE MEDICAL EQUIPMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-829-1799
Mailing Address - Street 1:105 SOUTHPARK BLVD
Mailing Address - Street 2:STE A101
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-829-1799
Mailing Address - Fax:904-829-0549
Practice Address - Street 1:105 SOUTHPARK BLVD
Practice Address - Street 2:STE A101
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-829-1799
Practice Address - Fax:904-829-0549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1689332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025524600Medicaid
FLR9312OtherBLUE CROSS BLUE SHIELD
FL025524600Medicaid