Healthcare Provider Details

I. General information

NPI: 1578635066
Provider Name (Legal Business Name): L.A. MEDICAL SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 S HIGHWAY 421 STE 2
MANCHESTER KY
40962
US

IV. Provider business mailing address

1621 S HIGHWAY 421 STE 2
MANCHESTER KY
40962-7514
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-9140
  • Fax: 606-598-0471
Mailing address:
  • Phone: 606-599-9140
  • Fax: 606-598-0471

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 Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. DONNA JACKSON
Title or Position: OWNER
Credential:
Phone: 606-599-9140