Healthcare Provider Details

I. General information

NPI: 1598068512
Provider Name (Legal Business Name): FUNDAMENTAL MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7114 RESEDA BLVD
RESEDA CA
91335-4210
US

IV. Provider business mailing address

7114 RESEDA BLVD
RESEDA CA
91335-4210
US

V. Phone/Fax

Practice location:
  • Phone: 805-230-2220
  • Fax: 805-230-2229
Mailing address:
  • Phone: 805-230-2220
  • Fax: 805-230-2229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number54837
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number54837
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number54837
License Number StateCA

VIII. Authorized Official

Name: MR. GRIGORY ATKOZYAN
Title or Position: PRESIDENT
Credential:
Phone: 805-230-2220