Healthcare Provider Details

I. General information

NPI: 1679374565
Provider Name (Legal Business Name): CLYDE MEDICAL SUPPLIERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 S PERRYVILLE RD
ROCKFORD IL
61108-8209
US

IV. Provider business mailing address

2205 S PERRYVILLE RD # 464
ROCKFORD IL
61108-8209
US

V. Phone/Fax

Practice location:
  • Phone: 608-581-5711
  • Fax:
Mailing address:
  • Phone: 608-581-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. CLYDE HARRIS JR.
Title or Position: CEO
Credential:
Phone: 608-581-5711