Provider Demographics
NPI:1164691598
Name:MEDLIFE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:MEDLIFE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-908-5666
Mailing Address - Street 1:2191 NORTHLAKE PKWY
Mailing Address - Street 2:SUITE-J BLDG #11
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4166
Mailing Address - Country:US
Mailing Address - Phone:770-908-5666
Mailing Address - Fax:770-908-5675
Practice Address - Street 1:2191 NORTHLAKE PKWY
Practice Address - Street 2:SUITE-J BLDG #11
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4166
Practice Address - Country:US
Practice Address - Phone:770-908-5666
Practice Address - Fax:770-908-5675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20020660338332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6102390001Medicare NSC