Provider Demographics
NPI:1790796639
Name:PENINSULA BIOMEDICAL INC
Entity Type:Organization
Organization Name:PENINSULA BIOMEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-430-9066
Mailing Address - Street 1:PO BOX 66149
Mailing Address - Street 2:108 WHISPERING PINES DR SUITE 115
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066
Mailing Address - Country:US
Mailing Address - Phone:831-430-9066
Mailing Address - Fax:831-430-9068
Practice Address - Street 1:500-01 WAIT AVE
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:919-556-8934
Practice Address - Fax:919-556-0693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00508332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010107199Medicaid
NC0428VOtherBCBS NC
KY9001254300Medicaid
KY9001254300Medicaid