Provider Demographics
NPI:1720498926
Name:MEDICARE ADVANTAGE TECH LLC
Entity Type:Organization
Organization Name:MEDICARE ADVANTAGE TECH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:FELIX
Authorized Official - Last Name:DEVISSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-339-5746
Mailing Address - Street 1:4821 SHADY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-6004
Mailing Address - Country:US
Mailing Address - Phone:804-339-5746
Mailing Address - Fax:804-612-8671
Practice Address - Street 1:4821 SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-6004
Practice Address - Country:US
Practice Address - Phone:804-339-5746
Practice Address - Fax:804-612-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS5034840332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies