Provider Demographics
NPI:1023425014
Name:MIJARES MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:MIJARES MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUEL
Authorized Official - Middle Name:MIJARES
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-436-2070
Mailing Address - Street 1:3276 BUFORD DR STE 104-333
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3276 BUFORD DR STE 104-333
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-5702
Practice Address - Country:US
Practice Address - Phone:404-436-2070
Practice Address - Fax:877-548-2685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies