Provider Demographics
NPI:1063749042
Name:180 MEDICAL, INC.
Entity type:Organization
Organization Name:180 MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-443-2985
Mailing Address - Street 1:8516 NW EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-6010
Mailing Address - Country:US
Mailing Address - Phone:877-688-2729
Mailing Address - Fax:888-718-0633
Practice Address - Street 1:1520 N HEARNE AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-7155
Practice Address - Country:US
Practice Address - Phone:318-798-4977
Practice Address - Fax:888-718-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADME.000354332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1016501Medicaid