Provider Demographics
NPI:1710266150
Name:PROCARE DIRECT LLC
Entity Type:Organization
Organization Name:PROCARE DIRECT LLC
Other - Org Name:PROCARE DIRECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-709-7080
Mailing Address - Street 1:105 S STATE ST
Mailing Address - Street 2:#602
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5419
Mailing Address - Country:US
Mailing Address - Phone:801-709-7080
Mailing Address - Fax:888-209-4417
Practice Address - Street 1:1189 S 1680 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5419
Practice Address - Country:US
Practice Address - Phone:801-709-7080
Practice Address - Fax:888-209-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6625400001Medicare NSC