Healthcare Provider Details

I. General information

NPI: 1376861054
Provider Name (Legal Business Name): MEDICAL DIRECT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21222 30TH DR SE SUITE 210
BOTHELL WA
98021-7019
US

IV. Provider business mailing address

21222 30TH DR SE SUITE 210
BOTHELL WA
98021-7019
US

V. Phone/Fax

Practice location:
  • Phone: 206-730-4026
  • Fax: 425-820-0831
Mailing address:
  • Phone: 206-730-4026
  • Fax: 425-820-0831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number602853461
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MIKE CONFORTO
Title or Position: PRESIDENT
Credential:
Phone: 206-730-4026