Provider Demographics
NPI:1386895746
Name:PROVIDACARE MEDICAL SUPPLY LTD
Entity type:Organization
Organization Name:PROVIDACARE MEDICAL SUPPLY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BLUMENSHEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-733-6518
Mailing Address - Street 1:3721 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1645
Mailing Address - Country:US
Mailing Address - Phone:512-733-6518
Mailing Address - Fax:512-795-9185
Practice Address - Street 1:831 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2103
Practice Address - Country:US
Practice Address - Phone:218-727-5555
Practice Address - Fax:218-727-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies