Basic Information
Provider Information | |||||||||
NPI: | 1144663444 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA HOME MEDICAL SUPPLY INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COLONIAL MEDICAL SUPPLIES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 614 E ALTAMONTE DR | ||||||||
Address2: |   | ||||||||
City: | ALTAMONTE SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 327014803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078496455 | ||||||||
FaxNumber: | 4078496458 | ||||||||
Practice Location | |||||||||
Address1: | 5100 POPLAR AVE | ||||||||
Address2: | SUITE 2700 | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381374000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007470246 | ||||||||
FaxNumber: | 8004877163 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2013 | ||||||||
LastUpdateDate: | 04/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUINSMA | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4078496455 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 1313277 | FL | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.