Provider Demographics
NPI:1790959187
Name:MAXICARE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:MAXICARE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EFIONG
Authorized Official - Middle Name:EYO
Authorized Official - Last Name:MBABA
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:770-907-0194
Mailing Address - Street 1:804 COMMERCE BLVD
Mailing Address - Street 2:SUITE A-32
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-7198
Mailing Address - Country:US
Mailing Address - Phone:770-907-0194
Mailing Address - Fax:770-907-0195
Practice Address - Street 1:804 COMMERCE BLVD
Practice Address - Street 2:SUITE A-32
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-7198
Practice Address - Country:US
Practice Address - Phone:770-907-0194
Practice Address - Fax:770-907-0195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06-19916332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA379763323AMedicaid
GA379763323AMedicaid