Provider Demographics
NPI:1982095139
Name:FOSSIL MEDICAL LLC
Entity type:Organization
Organization Name:FOSSIL MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BALENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-286-6019
Mailing Address - Street 1:2800 SOUTH 2ND STREET, SUITE D
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7025
Mailing Address - Country:US
Mailing Address - Phone:501-286-6019
Mailing Address - Fax:501-286-6021
Practice Address - Street 1:2800 SOUTH 2ND STREET, SUITE D
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7025
Practice Address - Country:US
Practice Address - Phone:501-286-6019
Practice Address - Fax:501-286-6021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies