Healthcare Provider Details

I. General information

NPI: 1154693778
Provider Name (Legal Business Name): MEDIQUIP REHABILITATIVE EQUIPMENT & SUPPLIES PLUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 PIO NONO AVE
MACON GA
31204-3536
US

IV. Provider business mailing address

808 PIO NONO AVE
MACON GA
31204-3536
US

V. Phone/Fax

Practice location:
  • Phone: 478-742-1300
  • Fax: 478-742-1302
Mailing address:
  • Phone: 478-742-1300
  • Fax: 478-742-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateGA

VIII. Authorized Official

Name: MS. AMY L DANIELLY
Title or Position: MANAGING OWNER
Credential:
Phone: 478-742-1300