Healthcare Provider Details

I. General information

NPI: 1750040465
Provider Name (Legal Business Name): HOMETOWN MEDICAL SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 WEST LN STE C
STOCKTON CA
95210-4548
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 209-472-1136
  • Fax: 209-472-1138
Mailing address:
  • Phone: 292-528-2116
  • 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 Number
License Number State

VIII. Authorized Official

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