Healthcare Provider Details

I. General information

NPI: 1962703454
Provider Name (Legal Business Name): LAKE AVENUE MEDICAL SUPPLY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 N LAKE AVE
PASADENA CA
91101-1215
US

IV. Provider business mailing address

467 N LAKE AVE
PASADENA CA
91101-1215
US

V. Phone/Fax

Practice location:
  • Phone: 626-405-0440
  • Fax: 626-405-0450
Mailing address:
  • Phone: 626-405-0440
  • Fax: 626-405-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number53974
License Number StateCA

VIII. Authorized Official

Name: MRS. RONEN SARAFIAN MALEK
Title or Position: PRESIDENT
Credential:
Phone: 626-405-0440