Provider Demographics
NPI:1912900945
Name:SCIENTECH MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:SCIENTECH MEDICAL SUPPLIES, INC.
Other - Org Name:SCIENTECH MEDICAL SUPPLIES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IYOBOSA
Authorized Official - Middle Name:O
Authorized Official - Last Name:JESUOROBO
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:770-471-4888
Mailing Address - Street 1:PO BOX 1635
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-8635
Mailing Address - Country:US
Mailing Address - Phone:770-471-4888
Mailing Address - Fax:770-471-4887
Practice Address - Street 1:7000 TARA BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1600
Practice Address - Country:US
Practice Address - Phone:770-417-4888
Practice Address - Fax:770-471-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20016604261332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA44181255AMedicaid
5338380001Medicare ID - Type Unspecified
GA5338380001Medicare NSC