=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760786776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDI QUIP SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2011
-----------------------------------------------------
Last Update Date | 01/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5057 HWY 42 EAST
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-310-4499
-----------------------------------------------------
Fax | 601-544-8404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5057 HWY 42 E.
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-310-4499
-----------------------------------------------------
Fax | 601-544-8404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER (SOLE MEMBER)
-----------------------------------------------------
Name | MR. CHAD EVERITTE TOMLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-310-4499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------