=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356322994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOSOM, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 08/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3385 BURNS RD SUITE 105
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-804-7636
-----------------------------------------------------
Fax | 561-804-7501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 W. CARMEL DR. SUITE 100
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-706-1080
-----------------------------------------------------
Fax | 317-574-8674
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/COO
-----------------------------------------------------
Name | MR. JAY JARRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-706-1080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | 1312686
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------