Healthcare Provider Details

I. General information

NPI: 1588646863
Provider Name (Legal Business Name): EAGLE PASS HOME MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2822 N VETERANS BLVD STE C
EAGLE PASS TX
78852-4819
US

IV. Provider business mailing address

1011 E 7TH ST
DEL RIO TX
78840-4162
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-0171
  • Fax: 830-757-0789
Mailing address:
  • Phone: 830-775-4060
  • Fax: 830-775-4038

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 Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number0082296
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: KENNETH EDWARD WIESE
Title or Position: GENERAL MANAGER
Credential:
Phone: 830-775-4060