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General NPI Number Information
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NPI Number | 1023395381
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Entity Type | Organization
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Legal Business Name | PROVIDA MEDICAL SUPPLY, INC.
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 11/10/2025
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Provider Practice Location Address
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Address Line | 333 IL-83 STE 206
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City | MUNDELEIN
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State | IL
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Zip | 60060-3117
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Country | US
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Telephone | 847-918-8085
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Fax | 847-881-0301
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Provider Business Mailing Address
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Address Line | 333 IL-83 STE 206
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City | MUNDELEIN
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State | IL
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Zip | 60060-3117
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Country | US
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Telephone | 847-918-8085
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Fax | 847-881-0301
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. LUDA TROYAK
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Credential |
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Telephone | 847-918-8085
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number | 203001360
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License Number State | IL
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