Provider Demographics
NPI:1821381328
Name:PARK MEDICAL WEAR, INC.
Entity Type:Organization
Organization Name:PARK MEDICAL WEAR, INC.
Other - Org Name:PARK MASTECTOMY SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-699-9612
Mailing Address - Street 1:1697 FREEDOM CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-7526
Mailing Address - Country:US
Mailing Address - Phone:866-699-9612
Mailing Address - Fax:702-405-7147
Practice Address - Street 1:1697 FREEDOM CT
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-7526
Practice Address - Country:US
Practice Address - Phone:866-699-9612
Practice Address - Fax:702-405-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier