Healthcare Provider Details

I. General information

NPI: 1619290657
Provider Name (Legal Business Name): DOC SUPPLY OF WEST TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LAKEVIEW RD SUITE D
SOMERVILLE TN
38068-9742
US

IV. Provider business mailing address

39 THREE WAY LN SUITE A
HUMBOLDT TN
38343-8561
US

V. Phone/Fax

Practice location:
  • Phone: 901-620-6900
  • Fax: 800-481-1206
Mailing address:
  • Phone: 800-306-5160
  • Fax: 800-481-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1014
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1014
License Number StateTN

VIII. Authorized Official

Name: MR. ROBERT T BALDRIDGE
Title or Position: OWNER
Credential: ATP
Phone: 800-306-5160