Provider Demographics
NPI:1619660149
Name:HOMETOWN MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:HOMETOWN MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-252-8211
Mailing Address - Street 1:9495 WINNETKA AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1618
Mailing Address - Country:US
Mailing Address - Phone:629-252-8211
Mailing Address - Fax:763-255-3972
Practice Address - Street 1:10700 JERSEY BLVD STE 190
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5127
Practice Address - Country:US
Practice Address - Phone:909-906-0962
Practice Address - Fax:909-966-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies