Healthcare Provider Details

I. General information

NPI: 1023366739
Provider Name (Legal Business Name): XCALIBUR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 HANOVER DR
MADISON GA
30650
US

IV. Provider business mailing address

1071 HANOVER DR
MADISON GA
30650
US

V. Phone/Fax

Practice location:
  • Phone: 678-500-9542
  • Fax: 678-500-9543
Mailing address:
  • Phone: 678-500-9542
  • Fax: 678-500-9543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number20170210145
License Number StateGA

VIII. Authorized Official

Name: MARTY RAY FRIERSON
Title or Position: OWNER
Credential:
Phone: 678-520-3464