Provider Demographics
NPI:1740205657
Name:MINERAL WELLS MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:MINERAL WELLS MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBBEKAH
Authorized Official - Middle Name:NADINE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-325-2706
Mailing Address - Street 1:PO BOX 1152
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76068-1152
Mailing Address - Country:US
Mailing Address - Phone:940-325-2706
Mailing Address - Fax:940-325-4130
Practice Address - Street 1:211 SW 25TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-8241
Practice Address - Country:US
Practice Address - Phone:940-325-2706
Practice Address - Fax:940-325-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0035334332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX513486OtherBLUE CROSS BLUE SHIELD
TX087075001Medicaid
TX015895801Medicaid
TX44995OtherAETNA MEDICAID
TX0565110001Medicare NSC