Healthcare Provider Details

I. General information

NPI: 1538431135
Provider Name (Legal Business Name): EXPEDIA MEDICAL SUPPLIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4416 MONROE RD STE E
CHARLOTTE NC
28205-7761
US

IV. Provider business mailing address

4416 MONROE RD STE E
CHARLOTTE NC
28205-7761
US

V. Phone/Fax

Practice location:
  • Phone: 704-236-9895
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: JACQUETTE DIAMOND LAND GINYARD
Title or Position: PRESIDENT
Credential:
Phone: 704-236-9895