=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407330590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIELD MEDICAL SUPPLIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2018
-----------------------------------------------------
Last Update Date | 09/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9286 OLD CASTLE RD
-----------------------------------------------------
City | VALLEY CENTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92082-5506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-901-8357
-----------------------------------------------------
Fax | 800-901-8357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 211241
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91921-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-901-8357
-----------------------------------------------------
Fax | 800-901-8357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JEREMY ADAM SIKES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-901-8357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------