Healthcare Provider Details

I. General information

NPI: 1104559236
Provider Name (Legal Business Name): HOMETOWN MEDICAL SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3093 WILJAN CT STE E
SANTA ROSA CA
95407-5750
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-800-3303
  • Fax: 707-440-0318
Mailing address:
  • Phone: 629-252-8211
  • Fax:

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 Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

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