=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083787865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST TEXAS RAYON SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5361 S STATE HIGH WAY 37
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-569-9023
-----------------------------------------------------
Fax | 903-569-9374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5361 S STATE HIGH WAY 37
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-569-9023
-----------------------------------------------------
Fax | 903-569-9374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL DIRECTOR
-----------------------------------------------------
Name | DANA CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-569-9023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------