Provider Demographics
NPI:1255386611
Name:MEDICAL HOME SUPPLY, INC.
Entity type:Organization
Organization Name:MEDICAL HOME SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-286-2000
Mailing Address - Street 1:1111 W EVANS AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80223-4058
Mailing Address - Country:US
Mailing Address - Phone:303-762-1263
Mailing Address - Fax:303-935-0718
Practice Address - Street 1:1111 W EVANS AVE
Practice Address - Street 2:UNIT A
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80223-4058
Practice Address - Country:US
Practice Address - Phone:303-762-1263
Practice Address - Fax:303-935-0718
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BYRAM HEALTHCARE CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08100075Medicaid
0396040001Medicare NSC