=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750878880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AJ DME SUPPLIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2018
-----------------------------------------------------
Last Update Date | 04/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 SARAH DR
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-1674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-424-8173
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 SARAH DR
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-1674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-424-8173
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MR. AON WAITE SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-424-8173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------