Healthcare Provider Details

I. General information

NPI: 1336320639
Provider Name (Legal Business Name): MED-DME SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 FOOTHILL BLVD
SUNLAND CA
91040-2849
US

IV. Provider business mailing address

8340 FOOTHILL BLVD
SUNLAND CA
91040-2849
US

V. Phone/Fax

Practice location:
  • Phone: 818-446-0700
  • Fax: 818-446-0064
Mailing address:
  • Phone: 818-446-0700
  • Fax: 818-446-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5724590001
License Number StateCA

VIII. Authorized Official

Name: LIA GORELISHVILI
Title or Position: OWNER
Credential:
Phone: 818-446-0700