Provider Demographics
NPI:1568449551
Name:DURABLE MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:DURABLE MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:OROBOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-719-9998
Mailing Address - Street 1:720 GLYNN ST N STE D1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6706
Mailing Address - Country:US
Mailing Address - Phone:770-719-9998
Mailing Address - Fax:770-719-9970
Practice Address - Street 1:720 GLYNN ST N
Practice Address - Street 2:#D-1
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-6706
Practice Address - Country:US
Practice Address - Phone:770-719-9998
Practice Address - Fax:770-719-9970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA302613978332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA932368359AMedicaid
GA932368359AMedicaid