Healthcare Provider Details

I. General information

NPI: 1811013014
Provider Name (Legal Business Name): LIA S ST. JUNIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PROF. THE MOBILITY STORE

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W WILLOW ST
LONG BEACH CA
90806-2830
US

IV. Provider business mailing address

PO BOX 821
FRESNO TX
77545-0821
US

V. Phone/Fax

Practice location:
  • Phone: 562-989-6306
  • Fax: 888-432-1395
Mailing address:
  • Phone: 562-989-6306
  • Fax: 888-432-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0086788
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0086788
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: