Provider Demographics
NPI:1316078199
Name:PROFESSIONAL MEDICAL SUPPLIES,DME, LLC
Entity type:Organization
Organization Name:PROFESSIONAL MEDICAL SUPPLIES,DME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLIVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PART OWNER
Authorized Official - Phone:956-277-0275
Mailing Address - Street 1:119 W COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LA FERIA
Mailing Address - State:TX
Mailing Address - Zip Code:78559-5108
Mailing Address - Country:US
Mailing Address - Phone:956-277-0275
Mailing Address - Fax:956-277-0269
Practice Address - Street 1:119 W COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:LA FERIA
Practice Address - State:TX
Practice Address - Zip Code:78559-5108
Practice Address - Country:US
Practice Address - Phone:956-277-0275
Practice Address - Fax:956-277-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0079427332BP3500X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191498801OtherMEDICAID CROSSOVER
TX191498802Medicaid
TX191498803OtherMEDICAID TEXAS HEALTH STEPS
TX191498801OtherMEDICAID CROSSOVER