Provider Demographics
NPI:1699779322
Name:FREEDOM MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:FREEDOM MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:POE
Authorized Official - Suffix:
Authorized Official - Credentials:ATP
Authorized Official - Phone:217-422-2220
Mailing Address - Street 1:2525 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3227
Mailing Address - Country:US
Mailing Address - Phone:217-422-2220
Mailing Address - Fax:217-422-2223
Practice Address - Street 1:2525 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3227
Practice Address - Country:US
Practice Address - Phone:217-422-2220
Practice Address - Fax:217-422-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000231332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid