Provider Demographics
NPI:1285979708
Name:FREEDOM MEDICAL SUPPLIES LLC.
Entity type:Organization
Organization Name:FREEDOM MEDICAL SUPPLIES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-469-2512
Mailing Address - Street 1:423 W YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3408
Mailing Address - Country:US
Mailing Address - Phone:509-469-2512
Mailing Address - Fax:509-469-2406
Practice Address - Street 1:423 W YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3408
Practice Address - Country:US
Practice Address - Phone:509-469-2512
Practice Address - Fax:509-469-2406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1285979708Medicaid
WA1285979708Medicaid