MEDICARE: MIJARES MEDICAL SUPPLY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1023425014
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIJARES MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	3276 BUFORD DR STE 104-333
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-5702
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3276 BUFORD DR STE 104-333
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-5702
Country	:	US
Telephone Number	:	404-436-2070
Fax Number	:	877-548-2685

Authorized Official
Title or Position	:	CEO
Name	:	RUEL MIJARES BAUTISTA JR.
Credential	:
Telephone Number	:	404-436-2070

Provider Enumeration Date	:	07/22/2014
Last Update Date	:	07/22/2014

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