Healthcare Provider Details

I. General information

NPI: 1790796639
Provider Name (Legal Business Name): PENINSULA BIOMEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500-01 WAIT AVE
WAKE FOREST NC
27587
US

IV. Provider business mailing address

PO BOX 66149 108 WHISPERING PINES DR SUITE 115
SCOTTS VALLEY CA
95066
US

V. Phone/Fax

Practice location:
  • Phone: 919-556-8934
  • Fax: 919-556-0693
Mailing address:
  • Phone: 831-430-9066
  • Fax: 831-430-9068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number00508
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number00508
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number00508
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010107199
Identifier TypeMEDICAID
Identifier StateVA
Identifier Issuer
# 2
Identifier0428V
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS NC
# 3
Identifier9001254300
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer

VIII. Authorized Official

Name: TONY REID
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 831-430-9066