=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427275619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAT FS2 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 08/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6359 W REDFIELD RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-776-0430
-----------------------------------------------------
Fax | 623-776-0643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6359 W REDFIELD RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-776-0430
-----------------------------------------------------
Fax | 623-776-0643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TOMM O KLEYENSTEUBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-628-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 20085770
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------