=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821171893
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIAL MEDICAL SUPPLY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3433 W KINGSLEY RD STE 9
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75041-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-864-5667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3433 W KINGSLEY RD STE 9
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75041-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-864-5667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHIKE NKWONTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-864-5667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 0066537
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------