MEDICARE: ALPHA OXY-MED 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	332BX2000X	Oxygen Equipment & Supplies (DME)	520	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386625457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA OXY-MED LLC

Provider Business Mailing Address
First Line	:	PO BOX 2529
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-2529
Country	:	US
Telephone Number	:	928-367-7415
Fax Number	:	928-367-7416

Provider Business Practice Location Address
First Line	:	674 E WHITE MOUNTAIN BLVD
Second Line	:	SUITE 3
City	:	PINETOP
State	:	AZ
Zip	:	85935
Country	:	US
Telephone Number	:	928-367-7415
Fax Number	:	928-367-7416

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RUSSELL E CHURCH
Credential	:
Telephone Number	:	928-367-7415

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	11/23/2007

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Directions to “ALPHA OXY-MED LLC ” Practice Location

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