Provider Demographics
NPI:1912537770
Name:ECMO PRN LLC
Entity Type:Organization
Organization Name:ECMO PRN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, CCRN-K
Authorized Official - Phone:510-274-0789
Mailing Address - Street 1:1246 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-1212
Mailing Address - Country:US
Mailing Address - Phone:510-274-0789
Mailing Address - Fax:
Practice Address - Street 1:1246 MISSION RD
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-1212
Practice Address - Country:US
Practice Address - Phone:510-274-0789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty
No242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionistGroup - Single Specialty