Provider Demographics
NPI:1053788703
Name:CERTICINE MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:CERTICINE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAVIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-285-9796
Mailing Address - Street 1:5331 SW MACADAM AVE
Mailing Address - Street 2:#214
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 SUNSET DR
Practice Address - Street 2:#B
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1260
Practice Address - Country:US
Practice Address - Phone:949-285-9796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK GRANDE HOLDINGS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies