MEDICARE: PAK MEDICAL, INC.

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1053479956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAK MEDICAL, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1042
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-1042
Country	:	US
Telephone Number	:	770-222-6678
Fax Number	:	770-222-6680

Provider Business Practice Location Address
First Line	:	5745 WENDY BAGWELL PKWY STE 32
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2885
Country	:	US
Telephone Number	:	770-222-6678
Fax Number	:	770-222-6680

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	ANITA KENNERLEY
Credential	:
Telephone Number	:	770-222-6678

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/15/2010

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