Provider Demographics
NPI:1760860811
Name:ADVANCE CARE DME & MEDICAL SUPPLIES, LLC
Entity Type:Organization
Organization Name:ADVANCE CARE DME & MEDICAL SUPPLIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-826-3735
Mailing Address - Street 1:199 CHARMANT PL STE 2
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4358
Mailing Address - Country:US
Mailing Address - Phone:601-605-2380
Mailing Address - Fax:
Practice Address - Street 1:199 CHARMANT PL STE 2
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4358
Practice Address - Country:US
Practice Address - Phone:601-605-2380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROYAL ALLIANCE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-09
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800242756OtherLISCENCE