=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134542673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RELIABLE MEDICAL SUPPLY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2014
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3555 9TH ST NW SUITE 300
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-218-3880
-----------------------------------------------------
Fax | 507-218-3881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9401 WINNETKA AVE N
-----------------------------------------------------
City | BROOKLYN PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-255-3800
-----------------------------------------------------
Fax | 763-255-3900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PAYOR RELATIONS
-----------------------------------------------------
Name | KILEY ANN RUSSELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 629-252-8211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------