=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205353695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUTOYS LEISURE PRODUCTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2017
-----------------------------------------------------
Last Update Date | 08/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 W HILLGROVE AVE
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60525-5823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-579-9055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2121
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60525-8221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-579-9055
-----------------------------------------------------
Fax | 708-579-0109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MOIRA STAGGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-579-9055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------