Provider Demographics
NPI:1558539684
Name:SOUTHERN MEDIC DURABLE EQUIPMENT
Entity Type:Organization
Organization Name:SOUTHERN MEDIC DURABLE EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANDRIA
Authorized Official - Middle Name:MERRLEN
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-271-3884
Mailing Address - Street 1:10101 HARWIN DR
Mailing Address - Street 2:STE. 369
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-1687
Mailing Address - Country:US
Mailing Address - Phone:713-271-3884
Mailing Address - Fax:832-252-1925
Practice Address - Street 1:10101 HARWIN DR
Practice Address - Street 2:STE. 369
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-1687
Practice Address - Country:US
Practice Address - Phone:713-271-3884
Practice Address - Fax:832-252-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102259332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194441502Medicaid
TX532812OtherBCBS OF TX
TX6068150001Medicare NSC