=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457739237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T. D. MEDICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2015
-----------------------------------------------------
Last Update Date | 12/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 CALLE MENDEZ VIGO W
-----------------------------------------------------
City | MAYAGUEZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00682-3234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-652-3683
-----------------------------------------------------
Fax | 787-652-3680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 N 29TH AVE
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33020-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-921-9099
-----------------------------------------------------
Fax | 954-921-1937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DOUGLAS EDWARD SHERRON
-----------------------------------------------------
Credential | ATP
-----------------------------------------------------
Telephone | 954-921-9099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 15747-F
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------