Healthcare Provider Details

I. General information

NPI: 1528251758
Provider Name (Legal Business Name): USMEDPED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 BRISTOL PL
ORANGE PARK FL
32073-5270
US

IV. Provider business mailing address

1642 BRISTOL PL
ORANGE PARK FL
32073-5270
US

V. Phone/Fax

Practice location:
  • Phone: 904-215-5951
  • Fax:
Mailing address:
  • Phone: 904-215-5951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD WILMONT MALLARD III
Title or Position: PRESIDENT
Credential:
Phone: 904-215-5951