=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912302126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEADALUS MEDICAL SUPPLY. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2014
-----------------------------------------------------
Last Update Date | 12/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23225 KINGSLAND BLVD STE 600
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-395-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23225 KINGSLAND BLVD STE 600
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-395-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | KATHRYN KALMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-395-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------