Provider Demographics
NPI:1710303169
Name:CONVALESCENT EQUIPMENT AND SUPPLY CO. INC.
Entity Type:Organization
Organization Name:CONVALESCENT EQUIPMENT AND SUPPLY CO. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-774-0083
Mailing Address - Street 1:1251 OFFICERS ROW
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3854
Mailing Address - Country:US
Mailing Address - Phone:877-552-3726
Mailing Address - Fax:425-774-0420
Practice Address - Street 1:1251 OFFICERS ROW
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3854
Practice Address - Country:US
Practice Address - Phone:877-552-3726
Practice Address - Fax:425-774-0420
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONVALESCENT EQUIPMENT AND SUPPLY CO. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-10
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600561377332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9006958Medicaid
OR500666641Medicaid