Healthcare Provider Details

I. General information

NPI: 1194629378
Provider Name (Legal Business Name): LILBURN MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 STONE MOUNTAIN HWY STE E
LILBURN GA
30047-4691
US

IV. Provider business mailing address

4765 STONE MOUNTAIN HWY STE E
LILBURN GA
30047-4691
US

V. Phone/Fax

Practice location:
  • Phone: 470-265-1333
  • Fax:
Mailing address:
  • Phone: 470-265-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL

VIII. Authorized Official

Name: DOLORES E ALVARADO
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 470-265-1333