=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235261553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER MEDICAL SUPPLY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 11/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2630 W. MANCHESTER BLVD SUITE C
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90305-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-750-7885
-----------------------------------------------------
Fax | 323-750-7890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2630 W. MANCHESTER BLVD SUITE C
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90305-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-750-7885
-----------------------------------------------------
Fax | 323-750-7890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MRS. MARY K FADIPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-750-7885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 46433
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------