=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588058309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PCD CLARY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2015
-----------------------------------------------------
Last Update Date | 03/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 N MAIN ST
-----------------------------------------------------
City | RICHLAND CENTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53581-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-649-2944
-----------------------------------------------------
Fax | 608-649-2945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 157 N MAIN ST
-----------------------------------------------------
City | RICHLAND CENTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53581-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-649-2944
-----------------------------------------------------
Fax | 608-649-2945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | PENNY CLARY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-649-2944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------