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Contact Information

Business Information

Type of Business:DME SupplierHealthcare Provider

How long have you been in business?
---Under 2 Years3-5 Years5-10 YearsOver 10 Years

How many new patients per month?
---Under 10 Patients10-25 Patients25-50 Patients50-100 PatientsOver 100 Patients

What is your average/estimated DME billing per month?
---Under $10,000$10,000-$25,000$25,000-$50,000$50,000-$100,000Over $100,000

What is your annual revenue?
---Under $100,000$100,000-$250,000$250,000-$500,000$500,000-$1,000,000Over $1,000,000

Do you have a DME License?YesNo

Are you Medicare Certified?YesNo

Do you plan to bill Medicare?YesNo

In what state(s) would you like to do business?
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

When can we reach you?

Questions or Comments?