Provider Demographics
NPI:1902855752
Name:EQUILIBRIUM MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:EQUILIBRIUM MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-455-2190
Mailing Address - Street 1:2100 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-3765
Mailing Address - Country:US
Mailing Address - Phone:954-455-2190
Mailing Address - Fax:954-455-5997
Practice Address - Street 1:2100 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-3765
Practice Address - Country:US
Practice Address - Phone:954-455-2190
Practice Address - Fax:954-455-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3232335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
5704590001Medicare NSC