Provider Demographics
NPI:1629257084
Name:MARTHA DALE KRISTIANSEN
Entity Type:Organization
Organization Name:MARTHA DALE KRISTIANSEN
Other - Org Name:MAK MEDICAL EQUIPMENT & RESPIRATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:KRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-684-5115
Mailing Address - Street 1:1413 ASTON AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2827
Mailing Address - Country:US
Mailing Address - Phone:601-684-5115
Mailing Address - Fax:601-684-5116
Practice Address - Street 1:1413 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2827
Practice Address - Country:US
Practice Address - Phone:601-684-5115
Practice Address - Fax:601-684-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS057128480332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9000OtherABP
MS00440487Medicaid
MS00440487Medicaid
MS00440487Medicaid