Provider Demographics
NPI:1033106208
Name:PRIMECARE DME SUPPLY INC
Entity type:Organization
Organization Name:PRIMECARE DME SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-585-0393
Mailing Address - Street 1:333 GORDON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6325
Mailing Address - Country:US
Mailing Address - Phone:407-585-0393
Mailing Address - Fax:407-585-0396
Practice Address - Street 1:333 GORDON ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6325
Practice Address - Country:US
Practice Address - Phone:407-585-0393
Practice Address - Fax:407-585-0396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1270680001Medicare ID - Type Unspecified