MEDICARE: ELIZABETH D.EBOLUM

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	166130802	TX
2	332B00000X	Durable Medical Equipment & Medical Supplies	166130801	TX

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790860344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELIZABETH D.EBOLUM

Provider Business Mailing Address
First Line	:	1704 N HAMPTON RD
Second Line	:	STE 207
City	:	DESOTO
State	:	TX
Zip	:	75115-8623
Country	:	US
Telephone Number	:	972-224-4500
Fax Number	:	972-224-4501

Provider Business Practice Location Address
First Line	:	1704 N HAMPTON RD
Second Line	:	STE 207
City	:	DESOTO
State	:	TX
Zip	:	75115-8623
Country	:	US
Telephone Number	:	972-224-4500
Fax Number	:	972-224-4501

Authorized Official
Title or Position	:	DIR OF OPERATIONS
Name	:	MRS. ELIZABETH D OPALEYE
Credential	:	RN
Telephone Number	:	972-224-4500

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	11/14/2008

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