Healthcare Provider Details

I. General information

NPI: 1538124953
Provider Name (Legal Business Name): FAYETTE MEDICAL SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 OLD AUSTIN HWY
BASTROP TX
78602-5128
US

IV. Provider business mailing address

PO BOX 1302
BASTROP TX
78602-1302
US

V. Phone/Fax

Practice location:
  • Phone: 512-332-0822
  • Fax: 512-332-0020
Mailing address:
  • Phone: 512-332-0822
  • Fax: 512-332-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225CA2500X
TaxonomyAssistive Technology Supplier Rehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number0040642
License Number StateTX

VIII. Authorized Official

Name: JONATHAN HERNANDEZ
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 979-968-6680