Healthcare Provider Details

I. General information

NPI: 1760197610
Provider Name (Legal Business Name): MILLBOURNE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 FOULKROD ST UNIT 306
PHILADELPHIA PA
19120-2125
US

IV. Provider business mailing address

649 FOULKROD ST UNIT 306
PHILADELPHIA PA
19120-2125
US

V. Phone/Fax

Practice location:
  • Phone: 610-553-7368
  • Fax:
Mailing address:
  • Phone: 610-553-7368
  • 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 Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: XIAOBIN LI
Title or Position: OWNER
Credential:
Phone: 215-813-9430