Provider Demographics
NPI:1851782155
Name:MYCROMED LLC
Entity Type:Organization
Organization Name:MYCROMED LLC
Other - Org Name:MSQUARED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-540-7464
Mailing Address - Street 1:2364 HIGHWAY 287 N
Mailing Address - Street 2:STE 109
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9208
Mailing Address - Country:US
Mailing Address - Phone:888-540-7464
Mailing Address - Fax:844-566-9276
Practice Address - Street 1:2364 HIGHWAY 287 N
Practice Address - Street 2:STE 109
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9208
Practice Address - Country:US
Practice Address - Phone:888-540-7464
Practice Address - Fax:844-566-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies