Healthcare Provider Details

I. General information

NPI: 1003995887
Provider Name (Legal Business Name): MEDIQUIP MEDICAL SUPPLIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 HUGH HOWELL RD SUITE 21
TUCKER GA
30084-5996
US

IV. Provider business mailing address

4404 HUGH HOWELL ROAD SUITE 21
TUCKER GA
30084-5996
US

V. Phone/Fax

Practice location:
  • Phone: 770-270-5808
  • Fax:
Mailing address:
  • Phone: 770-270-5808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number133568
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number133568
License Number StateGA

VIII. Authorized Official

Name: MRS. PRISCILLA WATT
Title or Position: CEO
Credential:
Phone: 770-498-7077