MEDICARE: SAS ANCILLARY SERVICES 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		GA

General Provider Information

NPI Number	:	1700110889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAS ANCILLARY SERVICES LLC

Provider Business Mailing Address
First Line	:	3100 FIVE FORKS TRICKUM RD SW
Second Line	:	SUITE 202
City	:	LILBURN
State	:	GA
Zip	:	30047-1890
Country	:	US
Telephone Number	:	770-736-3028
Fax Number	:	770-736-3345

Provider Business Practice Location Address
First Line	:	3100 FIVE FORKS TRICKUM RD SW
Second Line	:	SUITE 202
City	:	LILBURN
State	:	GA
Zip	:	30047-1890
Country	:	US
Telephone Number	:	770-736-3028
Fax Number	:	770-736-3345

Authorized Official
Title or Position	:	C.O.O.
Name	:	MS. KAREN DENISE FORRISTER
Credential	:
Telephone Number	:	770-736-3028

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	10/13/2010

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