Provider Demographics
NPI:1023502184
Name:CLEARWATER MEDICAL SUPPLY, INC
Entity type:Organization
Organization Name:CLEARWATER MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANISOV
Authorized Official - Middle Name:
Authorized Official - Last Name:VITALIV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-754-4341
Mailing Address - Street 1:4707 140TH AVE N STE 312
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3841
Mailing Address - Country:US
Mailing Address - Phone:727-754-4341
Mailing Address - Fax:
Practice Address - Street 1:4707 140TH AVE N STE 312
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762
Practice Address - Country:US
Practice Address - Phone:727-754-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies