Provider Demographics
NPI:1780855478
Name:MDK VENTURES LLC
Entity Type:Organization
Organization Name:MDK VENTURES LLC
Other - Org Name:MEDICAL DEPARTMENT STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCCORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-232-8585
Mailing Address - Street 1:752 COMMERCE DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-1744
Mailing Address - Country:US
Mailing Address - Phone:941-584-6154
Mailing Address - Fax:941-497-1030
Practice Address - Street 1:8595 COLLEGE PKWY
Practice Address - Street 2:UNIT 170
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5191
Practice Address - Country:US
Practice Address - Phone:239-482-6111
Practice Address - Fax:239-482-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL538 AHCA332B00000X
FL32 6681332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025612900Medicaid
FL4423600002Medicare NSC