MEDICARE: 123GERMFREE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1033741681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	123GERMFREE, LLC

Provider Business Mailing Address
First Line	:	4537 PRIME TER
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-7707
Country	:	US
Telephone Number	:	888-976-2525
Fax Number	:

Provider Business Practice Location Address
First Line	:	4537 PRIME TER
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-7707
Country	:	US
Telephone Number	:	888-976-2525
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CORDELL JETER
Credential	:
Telephone Number	:	888-976-2525

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	02/11/2020

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