Provider Demographics
NPI:1063406791
Name:SUPPORT SUPPLY CO
Entity type:Organization
Organization Name:SUPPORT SUPPLY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ODALYS
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-827-2322
Mailing Address - Street 1:2115 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2616
Mailing Address - Country:US
Mailing Address - Phone:305-827-2322
Mailing Address - Fax:305-827-0081
Practice Address - Street 1:2115 W 60TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2616
Practice Address - Country:US
Practice Address - Phone:305-827-2322
Practice Address - Fax:305-827-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3202292332BX2000X
FL70332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1089130001Medicare ID - Type Unspecified