Provider Demographics
NPI:1760551592
Name:SOUTHGATE DURABLE MEDICAL EQUIPMENTS
Entity Type:Organization
Organization Name:SOUTHGATE DURABLE MEDICAL EQUIPMENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:OSITA
Authorized Official - Last Name:NNAEMEKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-253-0021
Mailing Address - Street 1:3352 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6433
Mailing Address - Country:US
Mailing Address - Phone:662-253-0021
Mailing Address - Fax:662-253-0084
Practice Address - Street 1:3352 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6433
Practice Address - Country:US
Practice Address - Phone:662-253-0021
Practice Address - Fax:662-253-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2473332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04150524Medicaid
TN4582511OtherTENNCARE
MS04150524Medicaid