=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194822213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONVALESCENT EQUIPMENT & SUPPLY CO. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21829 HIGHWAY 99
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98026-8035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-774-0083
-----------------------------------------------------
Fax | 425-774-0420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21829 HIGHWAY 99
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98026-8035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-774-0083
-----------------------------------------------------
Fax | 425-774-0420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MIKE CORDOVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-774-0083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 600561377
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------