Provider Demographics
NPI:1104009802
Name:AGAPE MEDICAL SUPPLY & DURABLE MEDICAL EQUIPMENT
Entity Type:Organization
Organization Name:AGAPE MEDICAL SUPPLY & DURABLE MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-310-0803
Mailing Address - Street 1:8202 LULLWATER CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3963
Mailing Address - Country:US
Mailing Address - Phone:404-435-5931
Mailing Address - Fax:404-696-9826
Practice Address - Street 1:2564 PEYTON WOODS TRL SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-2157
Practice Address - Country:US
Practice Address - Phone:404-696-9826
Practice Address - Fax:404-696-9826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies