Provider Demographics
NPI:1336446004
Name:MAVERICK MEDICAL, INC.
Entity Type:Organization
Organization Name:MAVERICK MEDICAL, INC.
Other - Org Name:MEDICAL DYNAMICS ENTERPRISES, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY MAY
Authorized Official - Middle Name:
Authorized Official - Last Name:REAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-200-2544
Mailing Address - Street 1:PO BOX 1036
Mailing Address - Street 2:
Mailing Address - City:ZEPHYR COVE
Mailing Address - State:NV
Mailing Address - Zip Code:89448-1036
Mailing Address - Country:US
Mailing Address - Phone:707-200-2539
Mailing Address - Fax:707-573-0484
Practice Address - Street 1:276 KINGSBURY GRADE STE 210
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9804
Practice Address - Country:US
Practice Address - Phone:707-200-2539
Practice Address - Fax:707-573-0484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6523540001Medicare NSC
CA6523540001Medicare PIN