MEDICARE: IMMACULATE MEDICAL SUPPLIES, 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	332BX2000X	Oxygen Equipment & Supplies (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1265666192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMACULATE MEDICAL SUPPLIES, INC.

Provider Business Mailing Address
First Line	:	179 S WATSON RD
Second Line	:	SUITE 418
City	:	ARLINGTON
State	:	TX
Zip	:	76010-5416
Country	:	US
Telephone Number	:	682-551-9886
Fax Number	:	682-551-9886

Provider Business Practice Location Address
First Line	:	179 S WATSON RD
Second Line	:	SUITE 418
City	:	ARLINGTON
State	:	TX
Zip	:	76010-5416
Country	:	US
Telephone Number	:	682-551-9886
Fax Number	:	682-551-9886

Authorized Official
Title or Position	:	CEO
Name	:	MR. HILARY DAVID JR.
Credential	:
Telephone Number	:	682-551-9886

Provider Enumeration Date	:	05/06/2009
Last Update Date	:	05/06/2009

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