MEDICARE: QUALITY CUSTOM MEDICAL SUPPLY INC

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	1388246-DCA	NY

General Provider Information

NPI Number	:	1295249506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALITY CUSTOM MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	1727 SHEEPSHEAD BAY RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3606
Country	:	US
Telephone Number	:	718-676-5092
Fax Number	:	718-676-5093

Provider Business Practice Location Address
First Line	:	1727 SHEEPSHEAD BAY RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3606
Country	:	US
Telephone Number	:	718-676-5092
Fax Number	:	718-676-5093

Authorized Official
Title or Position	:	MANAGER
Name	:	MARINA BRONIVETSKAYA
Credential	:
Telephone Number	:	718-676-5092

Provider Enumeration Date	:	11/22/2017
Last Update Date	:	11/22/2017

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