Provider Demographics
NPI:1689457772
Name:MAIN STREET DME, INC.
Entity Type:Organization
Organization Name:MAIN STREET DME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:YURI
Authorized Official - Last Name:ONOUFRIENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-387-5620
Mailing Address - Street 1:2959 CHEROKEE ST NW STE 103C
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6522
Mailing Address - Country:US
Mailing Address - Phone:678-387-5620
Mailing Address - Fax:678-638-2857
Practice Address - Street 1:2959 CHEROKEE ST NW STE 103C
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6522
Practice Address - Country:US
Practice Address - Phone:678-387-5620
Practice Address - Fax:678-638-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies