Provider Demographics
NPI:1952871881
Name:PROVISION MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:PROVISION MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASANGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-812-0833
Mailing Address - Street 1:1000 SW 44TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3629
Mailing Address - Country:US
Mailing Address - Phone:405-812-0833
Mailing Address - Fax:
Practice Address - Street 1:1000 SW 44TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3629
Practice Address - Country:US
Practice Address - Phone:405-812-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies