Provider Demographics
NPI:1497097612
Name:BRAZOS MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:BRAZOS MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-675-6400
Mailing Address - Street 1:2005 OLD GREENBRIER RD
Mailing Address - Street 2:SUITE #106
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2649
Mailing Address - Country:US
Mailing Address - Phone:757-675-6400
Mailing Address - Fax:
Practice Address - Street 1:2005 OLD GREENBRIER RD
Practice Address - Street 2:SUITE #106
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2649
Practice Address - Country:US
Practice Address - Phone:757-675-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS4451904332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies