Provider Demographics
NPI:1467497347
Name:STREET HOME MEDICAL, INC
Entity type:Organization
Organization Name:STREET HOME MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-922-2889
Mailing Address - Street 1:1544 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3432
Mailing Address - Country:US
Mailing Address - Phone:478-922-2889
Mailing Address - Fax:478-922-9120
Practice Address - Street 1:1544 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3432
Practice Address - Country:US
Practice Address - Phone:478-922-2889
Practice Address - Fax:478-922-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA62133332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000545982AMedicaid
GA0477120001Medicare NSC