=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033325667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDTECH MEDICAL SUPPLY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 05/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1331 W GARVEY AVE N
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-2242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-962-7580
-----------------------------------------------------
Fax | 626-960-1659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2098
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91769-2098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-962-7580
-----------------------------------------------------
Fax | 626-960-1659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | OLAWALE AYOOLA OYETIBO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-962-7580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 49380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------