Provider Demographics
NPI:1972894863
Name:ELITE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:ELITE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODY
Authorized Official - Suffix:
Authorized Official - Credentials:LPED
Authorized Official - Phone:606-330-0570
Mailing Address - Street 1:1501 S MAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2091
Mailing Address - Country:US
Mailing Address - Phone:606-330-0570
Mailing Address - Fax:606-330-0571
Practice Address - Street 1:1501 S MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2091
Practice Address - Country:US
Practice Address - Phone:606-330-0570
Practice Address - Fax:606-330-0571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100193800Medicaid
KY6648450001Medicare NSC