=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639828692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINK WAVE CAPITAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2022
-----------------------------------------------------
Last Update Date | 03/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1307 RIDGE RD # 119
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75087-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-529-7179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5234 N O CONNOR BLVD APT 3309
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75039-5732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-309-0271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ADONTE BUSBY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-309-0271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------