Basic Information
| Provider Information | |||||||||
| NPI: | 1871569129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEEP SOUTH HOME MEDICAL EQUIPMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707650818 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 229 SUNRISE LANE | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346710471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | FLOURNEY | ||||||||
| AuthorizedOfficialFirstName: | RICKY | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3346719484 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 112249 | AL | N | Suppliers | Pharmacy | 332B00000X | 065560 | AL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 009918095 | 05 | AL | MEDICAID |