Provider Demographics
NPI:1770646150
Name:PROMED MEDICAL & RESPIRATORY SUPPLY, INC.
Entity Type:Organization
Organization Name:PROMED MEDICAL & RESPIRATORY SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:REENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHESSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-768-1500
Mailing Address - Street 1:1465 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-3009
Mailing Address - Country:US
Mailing Address - Phone:409-768-1500
Mailing Address - Fax:409-768-1551
Practice Address - Street 1:1465 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-3009
Practice Address - Country:US
Practice Address - Phone:409-768-1500
Practice Address - Fax:409-768-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010823501332B00000X
TX016685201332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010823501Medicaid
TX016685201Medicaid
TX1241420001Medicare NSC