Provider Demographics
NPI:1023366739
Name:XCALIBUR
Entity Type:Organization
Organization Name:XCALIBUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:FRIERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-520-3464
Mailing Address - Street 1:1071 HANOVER DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650
Mailing Address - Country:US
Mailing Address - Phone:678-500-9542
Mailing Address - Fax:678-500-9543
Practice Address - Street 1:1071 HANOVER DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650
Practice Address - Country:US
Practice Address - Phone:678-500-9542
Practice Address - Fax:678-500-9543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20170210145332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment