Provider Demographics
NPI:1659801488
Name:SUPERIOR HOME MEDICAL, INC
Entity Type:Organization
Organization Name:SUPERIOR HOME MEDICAL, INC
Other - Org Name:BOUTIQUE ON MAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:STEVENS
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, CFM
Authorized Official - Phone:704-225-0285
Mailing Address - Street 1:108 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5541
Mailing Address - Country:US
Mailing Address - Phone:704-225-0285
Mailing Address - Fax:704-225-0287
Practice Address - Street 1:201 N MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4753
Practice Address - Country:US
Practice Address - Phone:980-269-8382
Practice Address - Fax:980-269-8383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR HOME MEDICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-14
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFM02947224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704221Medicaid