Provider Demographics
NPI:1013602135
Name:BLACK BEAVER MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:BLACK BEAVER MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:AYRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-923-1993
Mailing Address - Street 1:123 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-2823
Mailing Address - Country:US
Mailing Address - Phone:405-923-1993
Mailing Address - Fax:
Practice Address - Street 1:123 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-2823
Practice Address - Country:US
Practice Address - Phone:405-923-1993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-05
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies