=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235308230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIFIC MEDICAL SUPPLIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2008
-----------------------------------------------------
Last Update Date | 04/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8700 RESEDA BLVD 204
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-882-2868
-----------------------------------------------------
Fax | 310-281-6111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8700 RESEDA BLVD 204
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-882-2868
-----------------------------------------------------
Fax | 310-281-6111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | OFFIONG E OFFIONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-882-2868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 48967
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------