Provider Demographics
NPI:1902077076
Name:HEAVENLY SENT INCONTINENCE SUPPLY
Entity Type:Organization
Organization Name:HEAVENLY SENT INCONTINENCE SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SALAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-442-0720
Mailing Address - Street 1:5959 S STAPLES ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3846
Mailing Address - Country:US
Mailing Address - Phone:361-442-0720
Mailing Address - Fax:
Practice Address - Street 1:5959 S STAPLES ST
Practice Address - Street 2:SUITE 104
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3846
Practice Address - Country:US
Practice Address - Phone:361-442-0720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0101990332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0101990OtherDEVICE DISTRIBUTOR