Healthcare Provider Details

I. General information

NPI: 1740356807
Provider Name (Legal Business Name): HOMEDIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 E COOLEY DRIVE # 104
COLTON CA
92324
US

IV. Provider business mailing address

671 E COOLEY DRIVE # 104 PO BOX 1344
COLTON CA
92324
US

V. Phone/Fax

Practice location:
  • Phone: 909-422-1121
  • Fax: 909-422-1191
Mailing address:
  • Phone: 909-422-1121
  • Fax: 909-422-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIE VERONICA FENTRESS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 909-422-1112