Healthcare Provider Details

I. General information

NPI: 1821076308
Provider Name (Legal Business Name): ELITE MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 RIDGE RD
WEST SENECA NY
14224-3332
US

IV. Provider business mailing address

1900 RIDGE RD
WEST SENECA NY
14224-3332
US

V. Phone/Fax

Practice location:
  • Phone: 716-712-0881
  • Fax: 716-712-0882
Mailing address:
  • Phone: 716-712-0881
  • Fax: 716-712-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY ANTHONY NIKIEL
Title or Position: OWNER
Credential:
Phone: 716-712-0881