Basic Information
| Provider Information | |||||||||
| NPI: | 1457396376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MRB ACQUISITION CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LINCARE POWERED MOBILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19387 US HIGHWAY 19 N | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337643102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275307700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1898 S CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321191584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663872668 | ||||||||
| FaxNumber: | 3862542844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCARTHY | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7275307700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | AO | ||||||||
| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 32:04483 | FL | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X | 8519 | FL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 121378400 | 05 | WY | MEDICAID | 5607416 | 05 | MT | MEDICAID | 342165100 | 05 | MN | MEDICAID | 1014691930001 | 05 | PA | MEDICAID | R9241 | 01 | FL | BLUE CROSS BLUE SHIELD FL | OTHER | 027940 | 05 | OR | MEDICAID | DE2695 | 05 | SC | MEDICAID | 807182800 | 05 | ID | MEDICAID | 022929600 | 05 | FL | MEDICAID | 200070320A | 05 | OK | MEDICAID | 9266409 AND TAX ID | 01 | AETNA | OTHER |