=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487860532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NRC MEDICALS SUPPLIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 368 W PIKE ST SUITE 204 B
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-985-1989
-----------------------------------------------------
Fax | 770-755-5682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 368 W PIKE ST SUITE 204 B
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-985-1989
-----------------------------------------------------
Fax | 770-755-5682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERRY TIPTON KWAKUMEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-985-1989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 20019192637
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------