=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144491804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JIREH DME SUPPLIES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2008
-----------------------------------------------------
Last Update Date | 11/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7505 PINES RD SUITE 1240
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71129-3935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-820-6476
-----------------------------------------------------
Fax | 877-676-8988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7505 PINES RD SUITE 1240
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71129-3935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-820-6476
-----------------------------------------------------
Fax | 877-676-8988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. TIERRA LATOYA WEST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-820-6476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------