MEDICARE: MILLBOURNE MEDICAL SUPPLY 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	332BN1400X	Nursing Facility Supplies (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1164944641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLBOURNE MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	6786 MARKET ST STE 101
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2431
Country	:	US
Telephone Number	:	610-553-7368
Fax Number	:	610-553-7414

Provider Business Practice Location Address
First Line	:	6786 MARKET ST STE 101
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2431
Country	:	US
Telephone Number	:	610-553-7368
Fax Number	:	610-553-7414

Authorized Official
Title or Position	:	OWNER
Name	:	XIAOBIN LI
Credential	:
Telephone Number	:	215-813-9430

Provider Enumeration Date	:	07/17/2017
Last Update Date	:	10/09/2019

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