Provider Demographics
NPI:1891856506
Name:LIFE SUPPLY CORPORATION
Entity Type:Organization
Organization Name:LIFE SUPPLY CORPORATION
Other - Org Name:DIVERSIFIED MEDICAL EQUIPMENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDEN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-239-1002
Mailing Address - Street 1:280 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-1244
Mailing Address - Country:US
Mailing Address - Phone:413-593-5555
Mailing Address - Fax:413-593-9530
Practice Address - Street 1:143 MILL ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3242
Practice Address - Country:US
Practice Address - Phone:978-537-8707
Practice Address - Fax:978-537-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1544144Medicaid
MA1151620002Medicare NSC