MEDICARE: LA BASE MEDICAL SUPPLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	1000491	TX

General Provider Information

NPI Number	:	1629406756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA BASE MEDICAL SUPPLY

Provider Business Mailing Address
First Line	:	7770 HIGHWAY 6 S # 367
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-3319
Country	:	US
Telephone Number	:	713-518-9360
Fax Number	:	281-302-6897

Provider Business Practice Location Address
First Line	:	9302 EAGLEWOOD GLEN TRL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-6285
Country	:	US
Telephone Number	:	713-518-9360
Fax Number	:	281-302-6897

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CALLISTUS EZEAKOR
Credential	:
Telephone Number	:	713-518-9360

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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Directions to “LA BASE MEDICAL SUPPLY ” Practice Location

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