Provider Demographics
NPI:1558887927
Name:FOOTHILL MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:FOOTHILL MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:REAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-492-2704
Mailing Address - Street 1:723 N 1890 W STE 38A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1333
Mailing Address - Country:US
Mailing Address - Phone:877-492-2704
Mailing Address - Fax:877-492-2716
Practice Address - Street 1:723 N 1890 W STE 38A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1333
Practice Address - Country:US
Practice Address - Phone:877-464-5846
Practice Address - Fax:877-492-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10186558-1714332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
622952500OtherU.S. DEPARTMENT OF LABOR WORKERS' COMPENSATION PROGRAMS
624014500OtherU.S. DEPARTMENT OF LABOR WORKERS' COMPENSATION PROGRAMS