Provider Demographics
NPI:1528269990
Name:CORAL DESERT MEDICAL SUPPLY, LLC
Entity type:Organization
Organization Name:CORAL DESERT MEDICAL SUPPLY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLYGARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-773-4300
Mailing Address - Street 1:PO BOX 912014
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84791
Mailing Address - Country:US
Mailing Address - Phone:435-773-4300
Mailing Address - Fax:435-773-4299
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:BUILDING B
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-773-4300
Practice Address - Fax:435-773-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF68728332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5990770001Medicare NSC