=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073069456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VCA EQUIPMENTS & SUPPLIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2016
-----------------------------------------------------
Last Update Date | 08/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7925 NW 12TH ST SUITE 401
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-1827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-854-8446
-----------------------------------------------------
Fax | 305-859-7849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7925 NW 12TH ST SUITE 401
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-1827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-854-8446
-----------------------------------------------------
Fax | 305-859-7849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | NIOVES PORTILLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-854-8446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------