Provider Demographics
NPI:1699125195
Name:BACK PAIN HOME SUPPLIES LLC
Entity type:Organization
Organization Name:BACK PAIN HOME SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDMOND
Authorized Official - Last Name:LOFTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-399-0089
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:DRUMRIGHT
Mailing Address - State:OK
Mailing Address - Zip Code:74030-0752
Mailing Address - Country:US
Mailing Address - Phone:918-352-9669
Mailing Address - Fax:844-316-6726
Practice Address - Street 1:116 S SKINNER AVE STE B
Practice Address - Street 2:
Practice Address - City:DRUMRIGHT
Practice Address - State:OK
Practice Address - Zip Code:74030-3642
Practice Address - Country:US
Practice Address - Phone:918-352-9669
Practice Address - Fax:844-316-6726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
7573030001Medicare NSC