Healthcare Provider Details

I. General information

NPI: 1992976187
Provider Name (Legal Business Name): LENDON L ELMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 VAUGHN DR
LUCEDALE MS
39452-3316
US

IV. Provider business mailing address

PO BOX 914
LUCEDALE MS
39452-0914
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-0032
  • Fax:
Mailing address:
  • Phone: 601-947-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberRCP0779
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: