Provider Demographics
NPI:1679343198
Name:WILD LORIS LLC
Entity Type:Organization
Organization Name:WILD LORIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KREUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-725-9786
Mailing Address - Street 1:3204 38TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2908
Mailing Address - Country:US
Mailing Address - Phone:800-795-1794
Mailing Address - Fax:330-492-5279
Practice Address - Street 1:3204 38TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2908
Practice Address - Country:US
Practice Address - Phone:440-725-9786
Practice Address - Fax:330-492-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies