Healthcare Provider Details

I. General information

NPI: 1427235530
Provider Name (Legal Business Name): OHLEY HOME MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 BROADWAY ST
MOUNT VERNON IL
62864-6724
US

IV. Provider business mailing address

4704 BROADWAY ST
MOUNT VERNON IL
62864-6724
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-5000
  • Fax: 618-244-5900
Mailing address:
  • Phone: 618-244-5000
  • Fax: 618-244-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JASON OHLEY
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 618-244-5000