=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235175670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABEL MEDICAL EQUIPMENT&SUPPLY CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10806 S US HIGHWAY 1
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-335-9977
-----------------------------------------------------
Fax | 772-335-9994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10806 S US HIGHWAY 1
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-335-9977
-----------------------------------------------------
Fax | 772-335-9994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. KENNETH A JACKSON
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 772-335-9977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1301
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------