Healthcare Provider Details

I. General information

NPI: 1083304604
Provider Name (Legal Business Name): POWER WHEELS MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 W AVENUE J STE 105
LANCASTER CA
93534-2881
US

IV. Provider business mailing address

1647 W AVENUE J STE 105
LANCASTER CA
93534-2881
US

V. Phone/Fax

Practice location:
  • Phone: 661-471-9081
  • Fax:
Mailing address:
  • Phone: 661-471-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDY E DEVINE
Title or Position: MANAGER
Credential:
Phone: 323-459-3047