=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003204397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XENCO MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2015
-----------------------------------------------------
Last Update Date | 01/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9930 MESA RIM RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-202-1522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9930 MESA RIM RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-202-1522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCE DIRECTOR
-----------------------------------------------------
Name | STEVE DAVILA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-202-1522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------