MEDICARE: P. STARK ENTERPRISES, 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	0000000405	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154371995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P. STARK ENTERPRISES, INC.

Provider Business Mailing Address
First Line	:	1100 HATCHER LN
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-3530
Country	:	US
Telephone Number	:	931-388-3766
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 HATCHER LN
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-3530
Country	:	US
Telephone Number	:	931-388-3766
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. PRESTON A STARK
Credential	:
Telephone Number	:	931-388-3766

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	03/10/2008

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