Provider Demographics
NPI:1629814728
Name:PROCARE MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:PROCARE MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FATME
Authorized Official - Middle Name:
Authorized Official - Last Name:TANANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-688-4000
Mailing Address - Street 1:125 KINGSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 KINGSBURY AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1552
Practice Address - Country:US
Practice Address - Phone:313-688-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies