Provider Demographics
NPI:1629068341
Name:BWDC MEDICAL EQUIPMENT CO.
Entity Type:Organization
Organization Name:BWDC MEDICAL EQUIPMENT CO.
Other - Org Name:BYRD WATSON MEDICAL EQUIP CO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-532-3045
Mailing Address - Street 1:123 N LOCUST ST
Mailing Address - Street 2:PO BOX 1747
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3242
Mailing Address - Country:US
Mailing Address - Phone:618-532-3045
Mailing Address - Fax:618-533-0572
Practice Address - Street 1:123 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5303
Practice Address - Country:US
Practice Address - Phone:618-532-3045
Practice Address - Fax:618-533-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000105332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL=========004Medicaid