Provider Demographics
NPI:1710923693
Name:QUEEN CITY HOME MEDICAL, LLC
Entity Type:Organization
Organization Name:QUEEN CITY HOME MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELIA
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-723-8009
Mailing Address - Street 1:11510 COLUMBIA ST
Mailing Address - Street 2:SUITE J
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2788
Mailing Address - Country:US
Mailing Address - Phone:229-723-8009
Mailing Address - Fax:229-723-8005
Practice Address - Street 1:11510 COLUMBIA ST
Practice Address - Street 2:SUITE J
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2788
Practice Address - Country:US
Practice Address - Phone:229-723-8009
Practice Address - Fax:229-723-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20015314787332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4943580001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER