MEDICARE: COPPER STAR MEDICAL SUPPLY

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)

General Provider Information

NPI Number	:	1609599802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPPER STAR MEDICAL SUPPLY

Provider Business Mailing Address
First Line	:	1155 S POWER RD STE 111
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-3716
Country	:	US
Telephone Number	:	602-960-4393
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 S POWER RD STE 111
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-3716
Country	:	US
Telephone Number	:	602-960-4393
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CLINICAL SERVICES/COMP
Name	:	SHERRY A MILDENBERGER
Credential	:	RT
Telephone Number	:	801-590-2714

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	09/22/2022

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