=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598160988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEST ELIMINATORS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2014
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3314 HARBOR BLVD
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-766-0902
-----------------------------------------------------
Fax | 941-766-0904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3314 HARBOR BLVD
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-766-0902
-----------------------------------------------------
Fax | 941-766-0904
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CONRAD ESTREM BURNS SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-766-0902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | JE80536
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------