=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578125183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHOCK AND AWE MARKETING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2019
-----------------------------------------------------
Last Update Date | 07/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 W VIRGINIA AVE
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40977-1616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-302-4004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1384
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40977-7384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-302-4004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ CEO
-----------------------------------------------------
Name | MR. CHRISTOPHER BRUCE THOMPSONQQQ
-----------------------------------------------------
Credential | 332B00000X
-----------------------------------------------------
Telephone | 606-302-4004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------