Provider Demographics
NPI:1528046836
Name:BRACKETTVILLE HOME MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:BRACKETTVILLE HOME MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-775-4060
Mailing Address - Street 1:1011 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4162
Mailing Address - Country:US
Mailing Address - Phone:830-775-4060
Mailing Address - Fax:730-775-4038
Practice Address - Street 1:302 MILITARY DR
Practice Address - Street 2:
Practice Address - City:BRACKETTVILLE
Practice Address - State:TX
Practice Address - Zip Code:78832
Practice Address - Country:US
Practice Address - Phone:830-563-2200
Practice Address - Fax:830-563-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0082284332BP3500X
332BX2000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX507642OtherINSURANCE PROVIDER ID
TX177105702Medicaid
TX177105701Medicaid
TX507642OtherINSURANCE PROVIDER ID