Provider Demographics
NPI:1285772343
Name:HOMETOWN MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:HOMETOWN MEDICAL SUPPLIES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-252-8211
Mailing Address - Street 1:9495 WINNETKA AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1618
Mailing Address - Country:US
Mailing Address - Phone:629-282-8211
Mailing Address - Fax:763-255-3972
Practice Address - Street 1:1274 ALMA CT
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5940
Practice Address - Country:US
Practice Address - Phone:408-279-3955
Practice Address - Fax:408-516-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA218051407332B00000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5942660001Medicare NSC