Healthcare Provider Details

I. General information

NPI: 1285772343
Provider Name (Legal Business Name): HOMETOWN MEDICAL SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/02/2025
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 ALMA CT
SAN JOSE CA
95112-5940
US

IV. Provider business mailing address

9495 WINNETKA AVE N STE 200
BROOKLYN PARK MN
55445-1618
US

V. Phone/Fax

Practice location:
  • Phone: 408-279-3955
  • Fax: 408-516-9662
Mailing address:
  • Phone: 629-282-8211
  • Fax: 763-255-3972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number218051407
License Number StateCA

VIII. Authorized Official

Name: KILEY ANN RUSSELL
Title or Position: SENIOR DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 629-252-8211