Provider Demographics
NPI:1609020221
Name:MAVERICK OXYGEN & RESPIRATORY EQUIPMENT, LLC
Entity type:Organization
Organization Name:MAVERICK OXYGEN & RESPIRATORY EQUIPMENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KITTLESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-225-4772
Mailing Address - Street 1:2510 ALLEN LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8580
Mailing Address - Country:US
Mailing Address - Phone:502-225-4772
Mailing Address - Fax:502-225-0605
Practice Address - Street 1:2510 ALLEN LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-8580
Practice Address - Country:US
Practice Address - Phone:502-225-4772
Practice Address - Fax:502-225-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYMG0450332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies