=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174754063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOMINION MEDICAL SUPPLIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2009
-----------------------------------------------------
Last Update Date | 07/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4110 GRANBY ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-201-5398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4110 GRANBY ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23504-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-201-5398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MISS TEREZ L PATTERSON
-----------------------------------------------------
Credential | B.A
-----------------------------------------------------
Telephone | 757-201-5398
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 904518
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------