Provider Demographics
NPI:1144456047
Name:PEACOCK MEDICAL EQUIPMENT AND HOME HEALTH CARE LLC
Entity type:Organization
Organization Name:PEACOCK MEDICAL EQUIPMENT AND HOME HEALTH CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:WELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-547-3224
Mailing Address - Street 1:1201 HIGHWAY 19 E BYPASS SUITE 3
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643
Mailing Address - Country:US
Mailing Address - Phone:423-547-3224
Mailing Address - Fax:180-041-9156
Practice Address - Street 1:1201 HIGHWAY 19 E BYPASS SUITE 3
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-547-3224
Practice Address - Fax:180-041-9156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM1334Medicaid
TN0000001020OtherTN BOARD FOR LICENSING HEALTHCARE FACILITIES DEPT OF HEALTH
TN1514122Medicaid
VA1144456047Medicaid
TN1514122Medicaid