Healthcare Provider Details

I. General information

NPI: 1568652568
Provider Name (Legal Business Name): PERFORMANCE MEDIEQUIP SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 POPPS FERRY RD
DIBERVILLE MS
39540-2378
US

IV. Provider business mailing address

4060 POPPS FERRY RD
DIBERVILLE MS
39540-2378
US

V. Phone/Fax

Practice location:
  • Phone: 662-719-8570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. JOEL WALTERS
Title or Position: OWNER
Credential:
Phone: 662-719-8570