=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669587515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON DURABLE MEDICAL EQUIPMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 09/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5510 S JACKSON RD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-9902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-682-6769
-----------------------------------------------------
Fax | 956-682-4447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5510 S JACKSON RD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-9902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-682-6769
-----------------------------------------------------
Fax | 956-682-4447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. AHMED MONIF NAZIF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-682-6769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 5232270001
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------