Provider Demographics
NPI:1518547728
Name:MBW700
Entity Type:Organization
Organization Name:MBW700
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:TARANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-526-5282
Mailing Address - Street 1:11319 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11319 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-2001
Practice Address - Country:US
Practice Address - Phone:913-526-5282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies