Provider Demographics
NPI:1962676189
Name:MDK VENTURES L.L.C
Entity Type:Organization
Organization Name:MDK VENTURES L.L.C
Other - Org Name:MEDICAL DEPARTMENT STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCCORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-232-8585
Mailing Address - Street 1:752 COMMERCE DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-1744
Mailing Address - Country:US
Mailing Address - Phone:941-584-6154
Mailing Address - Fax:877-497-1030
Practice Address - Street 1:4265 TAMIAMI TRL
Practice Address - Street 2:UNIT E
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2152
Practice Address - Country:US
Practice Address - Phone:941-637-7330
Practice Address - Fax:941-637-6582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1313157332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025612900Medicaid
FL025612900Medicaid