Provider Demographics
NPI:1386625457
Name:ALPHA OXY-MED LLC
Entity type:Organization
Organization Name:ALPHA OXY-MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-367-7415
Mailing Address - Street 1:PO BOX 2529
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-2529
Mailing Address - Country:US
Mailing Address - Phone:928-367-7415
Mailing Address - Fax:928-367-7416
Practice Address - Street 1:674 E WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935
Practice Address - Country:US
Practice Address - Phone:928-367-7415
Practice Address - Fax:928-367-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ520332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ853483Medicaid
5131730001Medicare NSC