Provider Demographics
NPI:1598038564
Name:AMERICAN EAGLE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:AMERICAN EAGLE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-769-3897
Mailing Address - Street 1:2612 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-2674
Mailing Address - Country:US
Mailing Address - Phone:409-769-3897
Mailing Address - Fax:409-783-9758
Practice Address - Street 1:2612 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-2674
Practice Address - Country:US
Practice Address - Phone:409-769-3897
Practice Address - Fax:409-783-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000851332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1000851OtherTEXAS REGULATORY LICENSE