Provider Demographics
NPI:1710977996
Name:EL-ELYON MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:EL-ELYON MEDICAL SUPPLY, LLC
Other - Org Name:EL-ELYON MEDICAL SUPPLY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:FEYISETAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-266-2030
Mailing Address - Street 1:2307 OAK LN
Mailing Address - Street 2:STE # 106
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-4885
Mailing Address - Country:US
Mailing Address - Phone:972-266-2030
Mailing Address - Fax:972-266-0355
Practice Address - Street 1:2307 OAK LN
Practice Address - Street 2:STE # 106
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4885
Practice Address - Country:US
Practice Address - Phone:972-266-2030
Practice Address - Fax:972-266-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0083793332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169961301Medicaid
TX169961302Medicaid
TX169961302Medicaid
TX5139940001Medicare NSC