Provider Demographics
NPI:1043326481
Name:PROVIDACARE MEDICAL SUPPLY LTD
Entity type:Organization
Organization Name:PROVIDACARE MEDICAL SUPPLY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-733-6518
Mailing Address - Street 1:PO BOX 27010
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-2010
Mailing Address - Country:US
Mailing Address - Phone:210-226-8700
Mailing Address - Fax:
Practice Address - Street 1:8300 OLD MCGREGOR RD
Practice Address - Street 2:STE 1B
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3600
Practice Address - Country:US
Practice Address - Phone:254-778-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0089310332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182572101Medicaid
TX182572101Medicaid