Healthcare Provider Details

I. General information

NPI: 1912123274
Provider Name (Legal Business Name): EDLUCY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W MAIN ST
FAIRFIELD IL
62837-2309
US

IV. Provider business mailing address

1010 W MAIN ST
FAIRFIELD IL
62837-2309
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-2531
  • Fax: 618-842-4036
Mailing address:
  • Phone: 618-842-2531
  • Fax: 618-842-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number054016079
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number054016079
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number054016079
License Number StateIL

VIII. Authorized Official

Name: LUCY A POTTS
Title or Position: OWNER
Credential:
Phone: 618-842-2531