Organization
BRACKETTVILLE HOME MEDICAL SUPPLY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KENNETH EDWARD WIESE (GENERAL MANAGER)
(830) 775-4060
Entity
Organization
Contact information
Practice address
302 MILITARY DR, BRACKETTVILLE, TX 78832
(830) 563-2200
(830) 563-2206
Mailing address
1011 E 7TH ST, DEL RIO, TX 78840-4162
(830) 775-4060
(730) 775-4038
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
0082284
TX
332BX2000X
Oxygen Equipment & Supplies (DME)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
177105701
—
TX
05
—
177105702
—
TX
01
—
507642
INSURANCE PROVIDER ID
TX
Enumeration date
01/06/2006
Last updated
08/20/2008
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