Healthcare Provider Details

I. General information

NPI: 1265666192
Provider Name (Legal Business Name): IMMACULATE MEDICAL SUPPLIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 S WATSON RD SUITE 418
ARLINGTON TX
76010-5416
US

IV. Provider business mailing address

179 S WATSON RD SUITE 418
ARLINGTON TX
76010-5416
US

V. Phone/Fax

Practice location:
  • Phone: 682-551-9886
  • Fax: 682-551-9886
Mailing address:
  • Phone: 682-551-9886
  • Fax: 682-551-9886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. HILARY DAVID JR.
Title or Position: CEO
Credential:
Phone: 682-551-9886