Provider Demographics
NPI:1609819218
Name:MEDIQUIP SUPPLIES AND SERVICES LLC
Entity Type:Organization
Organization Name:MEDIQUIP SUPPLIES AND SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLENNIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-243-9977
Mailing Address - Street 1:576 NORTHGATE DR.
Mailing Address - Street 2:UNIT B
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505
Mailing Address - Country:US
Mailing Address - Phone:970-243-9977
Mailing Address - Fax:970-254-0162
Practice Address - Street 1:576 NORTHGATE DR
Practice Address - Street 2:UNIT B
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-6906
Practice Address - Country:US
Practice Address - Phone:970-243-9977
Practice Address - Fax:970-254-0162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46284257Medicaid
CO46284257Medicaid