Provider Demographics
NPI:1689995300
Name:STATE WIDE DME LLC
Entity Type:Organization
Organization Name:STATE WIDE DME LLC
Other - Org Name:STATE WIDE DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-583-4620
Mailing Address - Street 1:3836 STOP38B
Mailing Address - Street 2:
Mailing Address - City:ZAPATA
Mailing Address - State:TX
Mailing Address - Zip Code:78076-2851
Mailing Address - Country:US
Mailing Address - Phone:956-583-4620
Mailing Address - Fax:956-583-4621
Practice Address - Street 1:3836 STOP38B
Practice Address - Street 2:
Practice Address - City:ZAPATA
Practice Address - State:TX
Practice Address - Zip Code:78076-2851
Practice Address - Country:US
Practice Address - Phone:956-583-4620
Practice Address - Fax:956-583-4621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies