=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144046400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE SUPPORT MED SUPPLIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2024
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8203 WILLOW PLACE DR S STE 145
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-893-7461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8203 WILLOW PLACE DR S STE 145
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-893-7461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. EHSAN IMAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-893-7461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------