Healthcare Provider Details

I. General information

NPI: 1730951716
Provider Name (Legal Business Name): 110 DME STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 ONE HORSE RD
ROSWELL NM
88201-0544
US

IV. Provider business mailing address

388 ONE HORSE RD
ROSWELL NM
88201-0544
US

V. Phone/Fax

Practice location:
  • Phone: 609-246-5397
  • Fax:
Mailing address:
  • Phone: 609-246-5397
  • 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: CLARINDA HUEBNER
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 609-246-5397