Healthcare Provider Details

I. General information

NPI: 1295862332
Provider Name (Legal Business Name): DIANE RAULERSONS HOME MEDICAL EQUIPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 ALICE ST
WAYCROSS GA
31501-6209
US

IV. Provider business mailing address

2019 ALICE ST
WAYCROSS GA
31501-6209
US

V. Phone/Fax

Practice location:
  • Phone: 912-283-4663
  • Fax: 912-338-0208
Mailing address:
  • Phone: 912-283-4663
  • Fax: 912-338-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number002687
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number002687
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number002687
License Number StateGA

VIII. Authorized Official

Name: MS. DIANE P RAULERSON
Title or Position: OWNER
Credential: RN
Phone: 912-283-4663