=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366690539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACES MEDICAL SUPPLY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2008
-----------------------------------------------------
Last Update Date | 08/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 FLORIDA ST SUITE D63
-----------------------------------------------------
City | MANDEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70448-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-377-2120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 FLORIDA ST SUITE D63
-----------------------------------------------------
City | MANDEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70448-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ALEXEY AMELCHENKO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-377-2120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 19D1087465
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------