Provider Demographics
NPI:1538419072
Name:CITY WIDE VILLAGE MATTRESS
Entity type:Organization
Organization Name:CITY WIDE VILLAGE MATTRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:JENNINGS
Authorized Official - Last Name:BROCIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-744-5212
Mailing Address - Street 1:700 W JEFFERSON ST
Mailing Address - Street 2:ROUTE 52
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-7608
Mailing Address - Country:US
Mailing Address - Phone:815-744-5212
Mailing Address - Fax:815-744-5620
Practice Address - Street 1:700 W JEFFERSON ST
Practice Address - Street 2:ROUTE 52
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-7608
Practice Address - Country:US
Practice Address - Phone:815-744-5212
Practice Address - Fax:815-744-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment