Healthcare Provider Details

I. General information

NPI: 1699779322
Provider Name (Legal Business Name): FREEDOM MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 N MAIN ST
DECATUR IL
62526-3227
US

IV. Provider business mailing address

2525 N MAIN ST
DECATUR IL
62526-3227
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-2220
  • Fax: 217-422-2223
Mailing address:
  • Phone: 217-422-2220
  • Fax: 217-422-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203000231
License Number StateIL

VIII. Authorized Official

Name: MRS. CANDACE POE
Title or Position: OWNER/ MANAGER
Credential: ATP
Phone: 217-422-2220