Provider Demographics
NPI:1669918009
Name:BLOOMINGTON MEDICAL DISTRIBUTION LLC
Entity type:Organization
Organization Name:BLOOMINGTON MEDICAL DISTRIBUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-306-7574
Mailing Address - Street 1:2045 W GRAND AVE
Mailing Address - Street 2:STE B #97551
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:309-306-7574
Mailing Address - Fax:
Practice Address - Street 1:1111 TRINITY LN
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8111
Practice Address - Country:US
Practice Address - Phone:309-306-7574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies