Provider Demographics
NPI:1770680803
Name:VALLEY REGIONAL MEDICAL SUPPLY
Entity Type:Organization
Organization Name:VALLEY REGIONAL MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-223-4422
Mailing Address - Street 1:518 3RD ST
Mailing Address - Street 2:PO BOX 1134
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2402
Mailing Address - Country:US
Mailing Address - Phone:815-223-4422
Mailing Address - Fax:815-223-4429
Practice Address - Street 1:518 3RD ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2402
Practice Address - Country:US
Practice Address - Phone:815-223-4422
Practice Address - Fax:815-223-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid