Provider Demographics
NPI:1609829399
Name:JASPER MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:JASPER MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-295-0044
Mailing Address - Street 1:4330 HIGHWAY 78 E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8905
Mailing Address - Country:US
Mailing Address - Phone:205-295-0044
Mailing Address - Fax:205-295-0028
Practice Address - Street 1:4330 HIGHWAY 78 E
Practice Address - Street 2:SUITE 103
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8905
Practice Address - Country:US
Practice Address - Phone:205-295-0044
Practice Address - Fax:205-295-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL060172332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5108210001Medicare ID - Type Unspecified