Provider Demographics
NPI:1588906960
Name:STAYWELL MEDICAL SUPPLIES
Entity type:Organization
Organization Name:STAYWELL MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEOGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-415-0311
Mailing Address - Street 1:18836 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2512
Mailing Address - Country:US
Mailing Address - Phone:718-740-0200
Mailing Address - Fax:718-740-0202
Practice Address - Street 1:18836 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11423-2512
Practice Address - Country:US
Practice Address - Phone:718-740-0200
Practice Address - Fax:718-740-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1463747332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7010950001Medicare NSC