Provider Demographics
NPI:1669587515
Name:JACKSON DURABLE MEDICAL EQUIPMENT LLC
Entity type:Organization
Organization Name:JACKSON DURABLE MEDICAL EQUIPMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:MONIF
Authorized Official - Last Name:NAZIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-682-6769
Mailing Address - Street 1:5510 S JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-9902
Mailing Address - Country:US
Mailing Address - Phone:956-682-6769
Mailing Address - Fax:956-682-4447
Practice Address - Street 1:5510 S JACKSON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-9902
Practice Address - Country:US
Practice Address - Phone:956-682-6769
Practice Address - Fax:956-682-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5232270001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171204401Medicaid
TX171204401Medicaid