Basic Information
| Provider Information | |||||||||
| NPI: | 1740433739 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE OXYGEN STORE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OXYGEN AND MORE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 115 JOHN MADDOX DR NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062901330 | ||||||||
| FaxNumber: | 7062901332 | ||||||||
| Practice Location | |||||||||
| Address1: | 8804A DAYTON PIKE | ||||||||
| Address2: | |||||||||
| City: | SODDY DAISY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373794306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234510515 | ||||||||
| FaxNumber: | 4234510516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 11/04/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YANCEY | ||||||||
| AuthorizedOfficialFirstName: | DELOS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7062901330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 0000000926 | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
No ID Information.