Healthcare Provider Details

I. General information

NPI: 1831024702
Provider Name (Legal Business Name): SPACE MEDICAL SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MEADOW LN
LAKE IN THE HILLS IL
60156-1229
US

IV. Provider business mailing address

308 MEADOW LN
LAKE IN THE HILLS IL
60156-1229
US

V. Phone/Fax

Practice location:
  • Phone: 331-200-9140
  • Fax:
Mailing address:
  • Phone: 331-200-9140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: HANAFI VAQAR AHMED
Title or Position: MANAGER
Credential:
Phone: 331-200-9140