Healthcare Provider Details

I. General information

NPI: 1902236177
Provider Name (Legal Business Name): EXPRESS CARE MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 W HURON ST
PONTIAC MI
48342-2100
US

IV. Provider business mailing address

12 W HURON ST
PONTIAC MI
48342-2100
US

V. Phone/Fax

Practice location:
  • Phone: 248-451-0073
  • Fax: 248-451-0082
Mailing address:
  • Phone: 248-451-0073
  • Fax: 248-451-0082

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 Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. RITA ILYASOV
Title or Position: PRESIDENT
Credential:
Phone: 248-451-0073