Provider Demographics
NPI:1457537383
Name:JERRY D REDWINE
Entity type:Organization
Organization Name:JERRY D REDWINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:REDWINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-272-4705
Mailing Address - Street 1:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:MULESHOE
Mailing Address - State:TX
Mailing Address - Zip Code:79347-1011
Mailing Address - Country:US
Mailing Address - Phone:806-272-4705
Mailing Address - Fax:806-272-3824
Practice Address - Street 1:111 E 3RD ST
Practice Address - Street 2:
Practice Address - City:MULESHOE
Practice Address - State:TX
Practice Address - Zip Code:79347-3801
Practice Address - Country:US
Practice Address - Phone:806-272-4705
Practice Address - Fax:806-272-3824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2296T332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0321040001Medicare NSC