=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790094530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTRESS GALLERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2010
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3125 LONE OAK RD SUITE B
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-5743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-554-7225
-----------------------------------------------------
Fax | 270-554-7242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3125 LONE OAK RD SUITE B
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-5743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-554-7225
-----------------------------------------------------
Fax | 270-554-7242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MS. PAULA GALE BREWER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-554-7242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------