Provider Demographics
NPI:1336350107
Name:PROVIDENT MEDICAL SUPPLY, INC
Entity type:Organization
Organization Name:PROVIDENT MEDICAL SUPPLY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:940-220-6440
Mailing Address - Street 1:1714 TEASLEY LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7795
Mailing Address - Country:US
Mailing Address - Phone:940-383-5733
Mailing Address - Fax:940-383-5700
Practice Address - Street 1:1714 TEASLEY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7795
Practice Address - Country:US
Practice Address - Phone:940-383-5733
Practice Address - Fax:940-383-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC08406987332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5322610001Medicare ID - Type UnspecifiedPROVIDER #