=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639305709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERMOMMY'S SUPERSTORE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2009
-----------------------------------------------------
Last Update Date | 06/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2411 RING RD SUITE 105
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-5929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-769-6693
-----------------------------------------------------
Fax | 270-769-0911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 268
-----------------------------------------------------
City | RINEYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40162-0268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-769-6693
-----------------------------------------------------
Fax | 270-769-0911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. REGINA RAE HAGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-769-6693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------