Healthcare Provider Details

I. General information

NPI: 1124935275
Provider Name (Legal Business Name): BLUE BRIDGE DME SUPPLIER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11206 LA SALLE AVE
LOS ANGELES CA
90047-4841
US

IV. Provider business mailing address

11206 LA SALLE AVE
LOS ANGELES CA
90047-4841
US

V. Phone/Fax

Practice location:
  • Phone: 631-784-3569
  • Fax:
Mailing address:
  • Phone: 631-784-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. DARIUS AARON COX
Title or Position: OWNER
Credential:
Phone: 631-784-3569