Provider Demographics
NPI:1972676682
Name:RUDY RYAN INC DBA MODERN MEDICAL PRODUCTS
Entity Type:Organization
Organization Name:RUDY RYAN INC DBA MODERN MEDICAL PRODUCTS
Other - Org Name:MODERN MEDICAL PRODUCTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-680-2010
Mailing Address - Street 1:2412 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-680-2010
Mailing Address - Fax:863-680-1870
Practice Address - Street 1:2412 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-680-2010
Practice Address - Fax:863-680-1870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL981332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL950845700Medicaid
FL0841010001Medicare NSC