Healthcare Provider Details

I. General information

NPI: 1417041112
Provider Name (Legal Business Name): ANGELES VISTA MEDICAL SUPPLIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11929 LOS NIETOS ROAD
SANTA FE SPRINGS CA
90670-2527
US

IV. Provider business mailing address

11929 LOS NIETOS ROAD
SANTA FE SPRINGS CA
90670-2527
US

V. Phone/Fax

Practice location:
  • Phone: 562-699-7200
  • Fax: 562-699-7210
Mailing address:
  • Phone: 562-699-7200
  • Fax: 562-699-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberDME02177F
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberDME02177F
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberDME02177F
License Number StateCA

VIII. Authorized Official

Name: MR. MARKSON BOLA ALABI
Title or Position: SOLE-PROPRIETOR
Credential: CO
Phone: 562-699-7200