Provider Demographics
NPI:1538488606
Name:CMB-1 RETAILER LLC
Entity Type:Organization
Organization Name:CMB-1 RETAILER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:BRYCE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:863-678-4808
Mailing Address - Street 1:3661 JAPONICA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAKE ESTATES
Mailing Address - State:FL
Mailing Address - Zip Code:33855
Mailing Address - Country:US
Mailing Address - Phone:863-692-9189
Mailing Address - Fax:
Practice Address - Street 1:1970 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4369
Practice Address - Country:US
Practice Address - Phone:863-678-4808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL440000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies