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General NPI Number Information
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NPI Number | 1538488606
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Entity Type | Organization
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Legal Business Name | CMB-1 RETAILER LLC
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Dates
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Enumeration Date | 05/27/2010
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Last Update Date | 05/27/2010
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Provider Practice Location Address
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Address Line | 1970 STATE ROAD 60 E
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City | LAKE WALES
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State | FL
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Zip | 33853-4369
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Country | US
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Telephone | 863-678-4808
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Fax |
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Provider Business Mailing Address
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Address Line | 3661 JAPONICA AVE
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City | INDIAN LAKE ESTATES
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State | FL
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Zip | 33855
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Country | US
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Telephone | 863-692-9189
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. CLINTON GEORGE BRYCE SR.
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Credential |
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Telephone | 863-678-4808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 440000
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License Number State | FL
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