Provider Demographics
NPI:1669488169
Name:MEDIRECT LATINO, INC.
Entity Type:Organization
Organization Name:MEDIRECT LATINO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:954-321-3540
Mailing Address - Street 1:2101 W ATLANTIC BLVD
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-2635
Mailing Address - Country:US
Mailing Address - Phone:954-321-3540
Mailing Address - Fax:954-321-3507
Practice Address - Street 1:2101 W ATLANTIC BLVD
Practice Address - Street 2:SUITE # 101
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-2635
Practice Address - Country:US
Practice Address - Phone:954-321-3540
Practice Address - Fax:954-321-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPPLIED FORMedicaid
5906000001Medicare NSC