Provider Demographics
NPI:1427235530
Name:OHLEY HOME MEDICAL, LLC
Entity type:Organization
Organization Name:OHLEY HOME MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:OHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-244-5000
Mailing Address - Street 1:4704 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6724
Mailing Address - Country:US
Mailing Address - Phone:618-244-5000
Mailing Address - Fax:618-244-5900
Practice Address - Street 1:4704 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6724
Practice Address - Country:US
Practice Address - Phone:618-244-5000
Practice Address - Fax:618-244-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6076960001Medicare NSC