=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518286202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPW ENTERPRISE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2010
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3686 LOWER CREEK DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-4291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-9011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3686 LOWER CREEK DRIVE
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-9011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PRINCIPAL
-----------------------------------------------------
Name | PATRICE LESHELLE DIXON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-838-9011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 20171
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------