Provider Demographics
NPI:1821494246
Name:PACIFIC DURABLE MEDICAL LLC
Entity Type:Organization
Organization Name:PACIFIC DURABLE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-267-4871
Mailing Address - Street 1:970 E BROADWAY
Mailing Address - Street 2:E #374
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:602-267-4871
Mailing Address - Fax:
Practice Address - Street 1:2441 E MADISON ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2638
Practice Address - Country:US
Practice Address - Phone:602-267-4871
Practice Address - Fax:480-302-5287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment