Healthcare Provider Details

I. General information

NPI: 1346531852
Provider Name (Legal Business Name): DERIDDER MEDICAL EQUIPMENT SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 MAHLON ST
DERIDDER LA
70634-4221
US

IV. Provider business mailing address

2661 RUSS ST
DERIDDER LA
70634-6035
US

V. Phone/Fax

Practice location:
  • Phone: 337-202-1911
  • Fax: 337-202-1913
Mailing address:
  • Phone: 337-463-5291
  • Fax: 337-463-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. BENTON RUDOLPH BLAKENEY
Title or Position: OWNER
Credential:
Phone: 337-463-5291