| Organization Name: | PROVIDA MEDICAL SUPPLY, INC. |
| NPI Number: | 1023395381 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LUDA TROYAK (PRESIDENT) |
| Mailing Address: | 1117 S Milwaukee Ave Suite D 5 Libertyville |
| State: | IL US |
| Postal Code: | 600485257 |
| Phone Number: | 8479188085 |
| Fax Number: | 8475730223 |
| NPI Enumeration Date: | 11/14/2011 |
| NPI Last Update Date: | 04/05/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332BX2000X |
| License Number: | 203001360 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | Oxygen Equipment & Supplies |
| Taxonomy Definition: | |