Provider Demographics
NPI:1609059971
Name:ADVANCED INFANT FORMULAS LLC
Entity Type:Organization
Organization Name:ADVANCED INFANT FORMULAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:SISLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-201-6231
Mailing Address - Street 1:10 CIRCLE C RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-3307
Mailing Address - Country:US
Mailing Address - Phone:719-201-6231
Mailing Address - Fax:719-392-4607
Practice Address - Street 1:10 CIRCLE C RD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-3307
Practice Address - Country:US
Practice Address - Phone:719-201-6231
Practice Address - Fax:719-392-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition