=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780920058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARS AND STRIPES MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2012
-----------------------------------------------------
Last Update Date | 01/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 W. STEPHEN FOSTER AVE SUITE B.
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-724-7883
-----------------------------------------------------
Fax | 502-290-1291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 449
-----------------------------------------------------
City | CRESTWOOD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40014-0449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-724-7883
-----------------------------------------------------
Fax | 502-290-1291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MEMBER
-----------------------------------------------------
Name | MR. DONALD P. COYLE
-----------------------------------------------------
Credential | RPSGT, RST
-----------------------------------------------------
Telephone | 502-724-7883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------