Healthcare Provider Details

I. General information

NPI: 1558827535
Provider Name (Legal Business Name): FAM MEDICAL SUPPLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 W 111TH PL
CHICAGO IL
60643-3648
US

IV. Provider business mailing address

1321 W 111TH PL
CHICAGO IL
60643-3648
US

V. Phone/Fax

Practice location:
  • Phone: 877-603-4226
  • Fax: 866-365-4843
Mailing address:
  • Phone: 877-603-4226
  • Fax: 866-365-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: KEVIN PENN
Title or Position: DIRECTOR
Credential:
Phone: 877-603-4226