Provider Demographics
NPI:1588664601
Name:COMPLETE MEDICAL SUPPLY&EQUIPMENT;LLC
Entity Type:Organization
Organization Name:COMPLETE MEDICAL SUPPLY&EQUIPMENT;LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BASSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-213-1055
Mailing Address - Street 1:PO BOX 1333
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1166
Mailing Address - Country:US
Mailing Address - Phone:678-213-1055
Mailing Address - Fax:678-213-1056
Practice Address - Street 1:6116 MABLETON PKWY SW STE 128
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-4305
Practice Address - Country:US
Practice Address - Phone:678-213-1055
Practice Address - Fax:678-213-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20100038403332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA631317089AMedicaid
GA6243760001Medicare NSC