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General NPI Number Information
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NPI Number | 1023366739
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Entity Type | Organization
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Legal Business Name | XCALIBUR
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Dates
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Enumeration Date | 08/28/2012
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Last Update Date | 08/28/2012
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Provider Practice Location Address
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Address Line | 1071 HANOVER DR
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City | MADISON
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State | GA
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Zip | 30650
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Country | US
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Telephone | 678-500-9542
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Fax | 678-500-9543
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Provider Business Mailing Address
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Address Line | 1071 HANOVER DR
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City | MADISON
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State | GA
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Zip | 30650
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Country | US
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Telephone | 678-500-9542
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Fax | 678-500-9543
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Authorized Official
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Title or Position | OWNER
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Name | MARTY RAY FRIERSON
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Credential |
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Telephone | 678-520-3464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 20170210145
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License Number State | GA
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