Healthcare Provider Details

I. General information

NPI: 1073355384
Provider Name (Legal Business Name): MAMMON EVANTUIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5951 LONDON LEE
TAMARAC FL
33321-4188
US

IV. Provider business mailing address

5951 LONDON LEE
TAMARAC FL
33321-4188
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 307-500-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: FRANKLIN POLIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 307-500-4200