=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801814843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COURAGE X
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 05/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 W NEW YORK AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-5226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-822-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 W NEW YORK AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-5226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-822-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CHRISTOPHER L. REA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-822-9909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 579
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------