Healthcare Provider Details

I. General information

NPI: 1255622742
Provider Name (Legal Business Name): 1534 VICTORY DME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 VICTORY BLVD
STATEN ISLAND NY
10314-3548
US

IV. Provider business mailing address

1534 VICTORY BLVD
STATEN ISLAND NY
10314-3548
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-3577
  • Fax: 718-667-3043
Mailing address:
  • Phone: 718-667-3577
  • Fax: 718-667-3043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KENNETH B CHAPMAN
Title or Position: MEMBER
Credential: MD
Phone: 718-667-3577