Provider Demographics
NPI:1164464707
Name:PROMED INC
Entity type:Organization
Organization Name:PROMED INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:DME SUPPLIER
Authorized Official - Phone:844-633-6287
Mailing Address - Street 1:27383 VIA INDUSTRIA
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3699
Mailing Address - Country:US
Mailing Address - Phone:808-396-1316
Mailing Address - Fax:808-356-0391
Practice Address - Street 1:1401 S BERETANIA ST
Practice Address - Street 2:SUITE 620
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1870
Practice Address - Country:US
Practice Address - Phone:808-396-1316
Practice Address - Fax:808-356-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI52514901Medicaid
HI1291710001Medicare NSC