=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700298742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLATE RIVER ENTERPRISES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2014
-----------------------------------------------------
Last Update Date | 05/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8954 S CONSTITUTION RTE
-----------------------------------------------------
City | SCOTTSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24590-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-996-2897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8954 S CONSTITUTION RTE
-----------------------------------------------------
City | SCOTTSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24590-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-996-2897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | MICHAEL FRATICELLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-996-2897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2705090728
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------