=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295790061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAYETTE MEDICAL SUPPLY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2006
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 362 E TRAVIS ST
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78945-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-968-6680
-----------------------------------------------------
Fax | 979-404-6082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 939
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78945-0939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-968-6680
-----------------------------------------------------
Fax | 979-859-7184
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | JONATHAN HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 979-968-6680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225CA2500X
-----------------------------------------------------
Taxonomy Name | Assistive Technology Supplier Rehabilitation Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | 0031424
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------