=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851831507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1240 HIGHWAY 54 W SUITE 504
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-4557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-731-1935
-----------------------------------------------------
Fax | 678-840-9446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1240 HIGHWAY 54 W SUITE 504
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-4557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-731-1935
-----------------------------------------------------
Fax | 678-840-9446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JALEN UBOH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-731-1935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------