MEDICARE: CAROLINA 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)		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720123862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	1802 SHELBY RD
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086-8900
Country	:	US
Telephone Number	:	704-730-9500
Fax Number	:	704-730-9501

Provider Business Practice Location Address
First Line	:	1802 SHELBY RD
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086-8900
Country	:	US
Telephone Number	:	704-730-9500
Fax Number	:	704-730-9501

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KENNETH WARE BLACK SR.
Credential	:
Telephone Number	:	704-730-9500

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	08/22/2020

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Directions to “CAROLINA MEDICAL SUPPLY LLC ” Practice Location

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