Healthcare Provider Details

I. General information

NPI: 1053788703
Provider Name (Legal Business Name): CERTICINE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SUNSET DR #B
LA GRANDE OR
97850-1260
US

IV. Provider business mailing address

5331 SW MACADAM AVE #214
PORTLAND OR
97239-6104
US

V. Phone/Fax

Practice location:
  • Phone: 949-285-9796
  • Fax:
Mailing address:
  • Phone:
  • 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 Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON SLAVIK
Title or Position: MEMBER
Credential:
Phone: 949-285-9796