MEDICARE: VICTORIAN 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1821023425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORIAN MEDICAL SUPPLY, LLC

Provider Business Mailing Address
First Line	:	2566 SHALLOWFORD RD NE
Second Line	:	SUITE 104-143
City	:	ATLANTA
State	:	GA
Zip	:	30345-1202
Country	:	US
Telephone Number	:	770-843-5380
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 HOWELL MILL RD NW
Second Line	:	#1210
City	:	ATLANTA
State	:	GA
Zip	:	30318-5559
Country	:	US
Telephone Number	:	770-843-5380
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MR. ADAM HARRIS
Credential	:
Telephone Number	:	770-843-5380

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/22/2020

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