=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962777599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIANCE MEDICAL SUPPLY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2012
-----------------------------------------------------
Last Update Date | 03/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10643 SENTINEL ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-737-2444
-----------------------------------------------------
Fax | 210-737-2445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2333 E 8TH ST
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-580-0171
-----------------------------------------------------
Fax | 432-580-7686
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SAMUEL DARREN BERRYHILL
-----------------------------------------------------
Credential | RRT,RCP
-----------------------------------------------------
Telephone | 432-580-0171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | 0046215
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------