Provider Demographics
NPI:1518098276
Name:MYSTIC MEDICAL EQUIPMENT INCORPORATED
Entity Type:Organization
Organization Name:MYSTIC MEDICAL EQUIPMENT INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:WENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-476-8811
Mailing Address - Street 1:23660 RESEARCH DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2643
Mailing Address - Country:US
Mailing Address - Phone:248-476-8811
Mailing Address - Fax:
Practice Address - Street 1:23660 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2643
Practice Address - Country:US
Practice Address - Phone:248-476-8811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3025219Medicaid
MI0431980001Medicare NSC
MI3025219Medicaid