MEDICARE: EXPEDIA MEDICAL SUPPLIES

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	343900000X	Non-emergency Medical Transport (VAN)
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1538431135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPEDIA MEDICAL SUPPLIES

Provider Business Mailing Address
First Line	:	4416 MONROE RD STE E
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7761
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4416 MONROE RD STE E
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7761
Country	:	US
Telephone Number	:	704-236-9895
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JACQUETTE DIAMOND LAND GINYARD
Credential	:
Telephone Number	:	704-236-9895

Provider Enumeration Date	:	01/30/2012
Last Update Date	:	02/17/2012

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Directions to “EXPEDIA MEDICAL SUPPLIES ” Practice Location

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