Provider Demographics
NPI:1386703460
Name:MID ATLANTIC MEDICAL LLC
Entity type:Organization
Organization Name:MID ATLANTIC MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RARYMOND
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEFORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-865-9858
Mailing Address - Street 1:207 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7177
Mailing Address - Country:US
Mailing Address - Phone:704-865-9858
Mailing Address - Fax:704-865-9848
Practice Address - Street 1:207 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7177
Practice Address - Country:US
Practice Address - Phone:704-865-9858
Practice Address - Fax:704-865-9848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704261Medicaid
NC5271370001Medicare ID - Type Unspecified