Provider Demographics
NPI:1346515343
Name:TYPE 2
Entity Type:Organization
Organization Name:TYPE 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-834-6699
Mailing Address - Street 1:5406 AUTUMN WOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-1553
Mailing Address - Country:US
Mailing Address - Phone:423-834-6699
Mailing Address - Fax:423-344-1070
Practice Address - Street 1:5793 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-4011
Practice Address - Country:US
Practice Address - Phone:423-834-6699
Practice Address - Fax:423-499-6408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN044113332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies