MEDICARE: VITAL MEDICAL SUPPLY INC.

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	002197618	CA

General Provider Information

NPI Number	:	1669601415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL MEDICAL SUPPLY INC.

Provider Business Mailing Address
First Line	:	4515 EAGLE ROCK BLVD.
Second Line	:	SUITE 145C
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3214
Country	:	US
Telephone Number	:	323-550-8888
Fax Number	:	323-550-8881

Provider Business Practice Location Address
First Line	:	4515 EAGLE ROCK BLVD
Second Line	:	SUITE 145C
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3214
Country	:	US
Telephone Number	:	323-550-8888
Fax Number	:	323-550-8881

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOSE GAVIOLA
Credential	:
Telephone Number	:	323-550-8888

Provider Enumeration Date	:	07/14/2009
Last Update Date	:	07/14/2009

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