MEDICARE: SAFE SOURCE DURABLE MEDICAL EQUIPMENT 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	:	1316625536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAFE SOURCE DURABLE MEDICAL EQUIPMENT LLC

Provider Business Mailing Address
First Line	:	155 WESTRIDGE PKWY STE 201
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-3050
Country	:	US
Telephone Number	:	770-278-9313
Fax Number	:	770-888-9759

Provider Business Practice Location Address
First Line	:	155 WESTRIDGE PKWY STE 201
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-3050
Country	:	US
Telephone Number	:	770-278-9313
Fax Number	:	770-888-9759

Authorized Official
Title or Position	:	OWNER
Name	:	SHARA LAMAR WHITE
Credential	:
Telephone Number	:	478-737-3337

Provider Enumeration Date	:	07/07/2023
Last Update Date	:	12/04/2023

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