Provider Demographics
NPI:1790860344
Name:ELIZABETH D.EBOLUM
Entity Type:Organization
Organization Name:ELIZABETH D.EBOLUM
Other - Org Name:ASSURED MEDICAL EQUIPMENT & SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:OPALEYE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:972-224-4500
Mailing Address - Street 1:1704 N HAMPTON RD
Mailing Address - Street 2:STE 207
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8623
Mailing Address - Country:US
Mailing Address - Phone:972-224-4500
Mailing Address - Fax:972-224-4501
Practice Address - Street 1:1704 N HAMPTON RD
Practice Address - Street 2:STE 207
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8623
Practice Address - Country:US
Practice Address - Phone:972-224-4500
Practice Address - Fax:972-224-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX166130801332B00000X
TX166130802332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166130801Medicaid
TX166130802Medicaid
TX166130802Medicaid
TX5099560001Medicare NSC