1205119294 NPI number — OMNIMED MEDICAL SUPPLY AND EQUIPMENT L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205119294 NPI number — OMNIMED MEDICAL SUPPLY AND EQUIPMENT L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNIMED MEDICAL SUPPLY AND EQUIPMENT L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205119294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
927 COMMERCIAL ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30012-4537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-648-8622
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3113 EDINBURGH CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30094-6863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-648-8622
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GOTIER
Authorized Official First Name:
ROGERS
Authorized Official Middle Name:
FULCHER
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-648-8622

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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