=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417934472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ULTIMED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2005
-----------------------------------------------------
Last Update Date | 03/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 MELVIN DR SUITE 21
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-509-8550
-----------------------------------------------------
Fax | 847-509-8552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 MELVIN DR SUITE 21
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-509-8550
-----------------------------------------------------
Fax | 847-509-8552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DANIEL WATERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-509-8550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------