Healthcare Provider Details

I. General information

NPI: 1518146455
Provider Name (Legal Business Name): INDIANOLA MEDICAL SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 SUNFLOWER AVENUE EXT BUILDING 1-A
INDIANOLA MS
38751-2333
US

IV. Provider business mailing address

612 SUNFLOWER AVENUE EXT BUILDING 1-A
INDIANOLA MS
38751-2333
US

V. Phone/Fax

Practice location:
  • Phone: 662-796-0705
  • Fax: 662-796-1270
Mailing address:
  • Phone: 662-796-0705
  • Fax: 662-796-1270

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 Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. TONYA THOMPSON
Title or Position: PRESIDENT
Credential:
Phone: 662-207-8598