Provider Demographics
NPI:1760445670
Name:JIM DANDY MEDICAL, INC.
Entity Type:Organization
Organization Name:JIM DANDY MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-615-9880
Mailing Address - Street 1:7959 FREDERICKSBURG RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3430
Mailing Address - Country:US
Mailing Address - Phone:210-615-9880
Mailing Address - Fax:
Practice Address - Street 1:7959 FREDERICKSBURG RD
Practice Address - Street 2:SUITE 111
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3430
Practice Address - Country:US
Practice Address - Phone:210-615-9881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000177332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177661902Medicaid
TX5165200001Medicare NSC