Provider Demographics
NPI:1316915689
Name:SPECIALTY MEDICAL SUPPLY OF LA
Entity type:Organization
Organization Name:SPECIALTY MEDICAL SUPPLY OF LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-397-3800
Mailing Address - Street 1:3426 CYPRESS ST
Mailing Address - Street 2:SUITE 13
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7319
Mailing Address - Country:US
Mailing Address - Phone:318-397-3800
Mailing Address - Fax:318-397-3860
Practice Address - Street 1:3426 CYPRESS ST
Practice Address - Street 2:SUITE 13
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7319
Practice Address - Country:US
Practice Address - Phone:318-397-3800
Practice Address - Fax:318-397-3860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2215507-001333600000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271446Medicaid
LA3882080001Medicare ID - Type Unspecified