MEDICARE: BEAUREGARD 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	332BX2000X	Oxygen Equipment & Supplies (DME)	40679808K	LA

General Provider Information

NPI Number	:	1679843098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAUREGARD MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	1004 N PINE ST
Second Line	:	B
City	:	DERIDDER
State	:	LA
Zip	:	70634-2818
Country	:	US
Telephone Number	:	337-842-6142
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 N PINE ST
Second Line	:	B
City	:	DERIDDER
State	:	LA
Zip	:	70634-2818
Country	:	US
Telephone Number	:	337-842-6142
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN LOFTIN
Credential	:
Telephone Number	:	337-842-6142

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

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