Provider Demographics
NPI:1205086154
Name:MEDIKWIP, LLC
Entity type:Organization
Organization Name:MEDIKWIP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-449-6960
Mailing Address - Street 1:3151 LENORA CHURCH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4823
Mailing Address - Country:US
Mailing Address - Phone:770-449-6960
Mailing Address - Fax:877-768-4658
Practice Address - Street 1:3151 LENORA CHURCH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-4823
Practice Address - Country:US
Practice Address - Phone:770-449-6960
Practice Address - Fax:877-768-4658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2010OCC-004793332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA783433216AMedicaid
GA6268370001Medicare NSC