| Organization Name: | MIJARES MEDICAL SUPPLY LLC |
| NPI Number: | 1023425014 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RUEL MIJARES BAUTISTA (CEO) |
| Mailing Address: | 3276 Buford Dr Ste 104-333 Buford |
| State: | GA US |
| Postal Code: | 305195702 |
| Phone Number: | 4044362070 |
| Fax Number: | 8775482685 |
| NPI Enumeration Date: | 07/22/2014 |
| NPI Last Update Date: | 07/22/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |