MEDICARE: ISLAND DURABLE MEDICAL EQUIPMENT, 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1497940035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND DURABLE MEDICAL EQUIPMENT, LLC

Provider Business Mailing Address
First Line	:	1908 STATE HWY 361
Second Line	:
City	:	PORT ARANSAS
State	:	TX
Zip	:	78373-4894
Country	:	US
Telephone Number	:	361-749-0908
Fax Number	:	361-749-1120

Provider Business Practice Location Address
First Line	:	1908 STATE HWY 361
Second Line	:
City	:	PORT ARANSAS
State	:	TX
Zip	:	78373-4894
Country	:	US
Telephone Number	:	361-749-0908
Fax Number	:	361-749-1120

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KATHRYN RICHARDS CARR
Credential	:
Telephone Number	:	361-749-0908

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	08/12/2008

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