Provider Demographics
NPI:1265764088
Name:DOC SUPPLY OF WEST TENNESSEE, LLC
Entity type:Organization
Organization Name:DOC SUPPLY OF WEST TENNESSEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BALDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:ATP
Authorized Official - Phone:800-306-5160
Mailing Address - Street 1:2192 EXPRESS DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:800-306-5160
Mailing Address - Fax:800-481-1206
Practice Address - Street 1:2192 EXPRESS DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:800-306-5160
Practice Address - Fax:800-481-1206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1014332BC3200X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6364310001Medicare NSC