=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679008676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENEFICIAL MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2017
-----------------------------------------------------
Last Update Date | 04/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 US HIGHWAY 9 STE 108 GROSSO OFFICE PARK
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-580-0660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 US HIGHWAY 9 STE 108 GROSSO OFFICE PARK
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-580-0660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | NELLY BAKSHIYEV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-580-0660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225000000X
-----------------------------------------------------
Taxonomy Name | Orthotic Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------