Provider Demographics
NPI:1922274521
Name:DLS MEDICAL EQUIPMENT PROVIDER
Entity Type:Organization
Organization Name:DLS MEDICAL EQUIPMENT PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-349-1012
Mailing Address - Street 1:4115 N 56TH ST
Mailing Address - Street 2:SUITE B165
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4115 N 56TH ST
Practice Address - Street 2:SUITE B165
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1269
Practice Address - Country:US
Practice Address - Phone:414-349-1012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR DESTINY, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41567700Medicaid