Provider Demographics
NPI:1861652745
Name:LARRY MCQUATER
Entity Type:Organization
Organization Name:LARRY MCQUATER
Other - Org Name:DIVERSIFIED MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-713-3366
Mailing Address - Street 1:240 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5260
Mailing Address - Country:US
Mailing Address - Phone:601-713-3366
Mailing Address - Fax:601-713-3388
Practice Address - Street 1:240 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5260
Practice Address - Country:US
Practice Address - Phone:601-713-3366
Practice Address - Fax:601-713-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25320136332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440848Medicaid
MS3977260001Medicare NSC