Provider Demographics
NPI:1851489843
Name:HOME MEDICAL PROFESSIONAL SERVICE
Entity Type:Organization
Organization Name:HOME MEDICAL PROFESSIONAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:DARNELLE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:478-471-7715
Mailing Address - Street 1:PO BOX 7967
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31209
Mailing Address - Country:US
Mailing Address - Phone:478-471-7715
Mailing Address - Fax:478-757-0234
Practice Address - Street 1:4480 RIVERSIDE DRIVE
Practice Address - Street 2:SUITE 11
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:478-471-7715
Practice Address - Fax:478-757-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4690630001Medicare ID - Type Unspecified