=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972226371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAGLEY MEDICAL SUPPLY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 S RANGELINE RD
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 463-999-9877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4
-----------------------------------------------------
City | WESTFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46074-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-517-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CRAIG KUNKLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-517-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------