Provider Demographics
NPI:1912654989
Name:BLACK RIVER MEDICAL SUPPLIES AND EQUIPMENT, LLC
Entity Type:Organization
Organization Name:BLACK RIVER MEDICAL SUPPLIES AND EQUIPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:843-355-5545
Mailing Address - Street 1:482 NELSON BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-4025
Mailing Address - Country:US
Mailing Address - Phone:843-355-5545
Mailing Address - Fax:
Practice Address - Street 1:482 NELSON BLVD
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4025
Practice Address - Country:US
Practice Address - Phone:843-355-5545
Practice Address - Fax:843-355-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies