M. DAVIS MANAGEMENT, INC.

Contacts

Phone	+1 407-206-0040
Fax	4072060010
Phone	+1 407-539-0303
Fax	4075390304

Authorized person

Name	STEPHEN P GRIGGS
Role	CEO
Phone	4072060040

Taxonomy

Taxonomy Code	332B00000X - Durable Medical Equipment & Medical Supplies
License Number	957
State	FL
Is Primary	No
Taxonomy Code	332BX2000X - Oxygen Equipment & Supplies (DME)
License Number	957
State	FL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	951869000
State	FL
Issuer	BC/BS PROVIDER NUMBER
Number	R8641
State	FL

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	532290
Sponsor’s telephone number	4072060040
Plan sponsor’s address	3325 BARTLETT BLVD., ORLANDO, FL, 32811

Signature of

Role	Plan administrator
Date	2015-07-30
Name of individual signing	JOSEPH RUSSELL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	532290
Sponsor’s telephone number	4072060040
Plan sponsor’s address	3325 BARTLETT BLVD., ORLANDO, FL, 32811

Signature of

Role	Plan administrator
Date	2015-07-30
Name of individual signing	JOSEPH RUSSELL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	532290
Sponsor’s telephone number	4072060040
Plan sponsor’s address	3325 BARTLETT BLVD, ORLANDO, FL, 32811

Plan administrator’s name and address

Administrator’s EIN	593143582
Plan administrator’s name	M DAVIS MANAGEMENT INC
Plan administrator’s address	3325 BARTLETT BLVD, ORLANDO, FL, 32811
Administrator’s telephone number	4072060040

Signature of

Role	Plan administrator
Date	2013-10-17
Name of individual signing	JOSEPH RUSSELL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	532290
Sponsor’s telephone number	4072060040
Plan sponsor’s address	3325 BARTLETT BLVD, ORLANDO, FL, 32811

Plan administrator’s name and address

Administrator’s EIN	593143582
Plan administrator’s name	M DAVIS MANAGEMENT INC
Plan administrator’s address	3325 BARTLETT BLVD, ORLANDO, FL, 32811
Administrator’s telephone number	4072060040

Signature of

Role	Plan administrator
Date	2013-10-17
Name of individual signing	JOSEPH RUSSELL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	532290
Sponsor’s telephone number	4072060040
Plan sponsor’s address	3325 BARTLETT BLVD, ORLANDO, FL, 32811

Plan administrator’s name and address

Administrator’s EIN	593143582
Plan administrator’s name	M DAVIS MANAGEMENT INC.
Plan administrator’s address	3325 BARTLETT BLVD, ORLANDO, FL, 32811
Administrator’s telephone number	4072060040

Signature of

Role	Plan administrator
Date	2011-05-13
Name of individual signing	M DAVIS MANAGEMENT INC.
Valid signature	Filed with authorized/valid electronic signature