MEDICARE: CENTRACARE 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	:	1598368755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRACARE MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	1200 6TH AVE N
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-2735
Country	:	US
Telephone Number	:	320-251-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 18TH AVE W
Second Line	:
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-2748
Country	:	US
Telephone Number	:	320-762-6036
Fax Number	:

Authorized Official
Title or Position	:	SR VP & CFO
Name	:	MICHAEL A BLAIR
Credential	:
Telephone Number	:	320-255-5665

Provider Enumeration Date	:	11/19/2020
Last Update Date	:	11/19/2020

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