Healthcare Provider Details

I. General information

NPI: 1578185104
Provider Name (Legal Business Name): ELITE SUPPLY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 03/04/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 BUS-US 401
RAEFORD NC
28376
US

IV. Provider business mailing address

PO BOX 417
RAEFORD NC
28376-0417
US

V. Phone/Fax

Practice location:
  • Phone: 910-565-2857
  • Fax:
Mailing address:
  • Phone:
  • Fax: 910-248-6258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: HARRY LAMONT SOUTHERLAND
Title or Position: PRESIDENT
Credential: JD
Phone: 910-978-9118