Provident Medical Supply, Inc

Primary specialty

Parenteral & Enteral Nutrition Supplies (DME)Taxonomy code 332BP3500X

License

C08406987 Issued in TX

Legal business name

PROVIDENT MEDICAL SUPPLY, INC

Practice address

1714 Teasley LN
Suite 101
Denton, TX 76205-7795

Phone

(940) 383-5733

Fax

(940) 383-5700

NPI assigned

May 24, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Royce Freebourn, R.N.

Title

Owner

Phone

(940) 220-6440

Specialties & licenses 1

Addresses

Other names 1

• Provident Medical Supply Other name

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1336350107",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1714 TEASLEY LN",
            "address_2": "SUITE 101",
            "city": "DENTON",
            "state": "TX",
            "postal_code": "762057795",
            "telephone_number": "940-383-5733",
            "fax_number": "940-383-5700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1714 TEASLEY LN",
            "address_2": "SUITE 101",
            "city": "DENTON",
            "state": "TX",
            "postal_code": "762057795",
            "telephone_number": "940-383-5733",
            "fax_number": "940-383-5700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENT MEDICAL SUPPLY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-24",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "FREEBOURN",
        "authorized_official_first_name": "ROYCE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "940-220-6440",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "R.N."
    },
    "taxonomies": [
        {
            "code": "332BP3500X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Parenteral & Enteral Nutrition",
            "state": "TX",
            "license": "C08406987",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Provident Medical Supply",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Parenteral & Enteral Nutrition Supplies (DME) in Denton, TX
• Providers in Denton, TX by specialty
• Parenteral & Enteral Nutrition Supplies (DME) in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.