Provider Demographics
NPI:1679777007
Name:EASYLIFE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:EASYLIFE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NWAFOR
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:OBIORAH
Authorized Official - Suffix:
Authorized Official - Credentials:DME
Authorized Official - Phone:240-476-9584
Mailing Address - Street 1:3395 LAWRENCEVILLE HWY
Mailing Address - Street 2:STE B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6408
Mailing Address - Country:US
Mailing Address - Phone:240-476-9584
Mailing Address - Fax:
Practice Address - Street 1:3395 LAWRENCEVILLE HWY
Practice Address - Street 2:STE B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6408
Practice Address - Country:US
Practice Address - Phone:240-476-9584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2007020341332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5929520001Medicare NSC