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General NPI Number Information
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NPI Number | 1265691562
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Entity Type | Organization
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Legal Business Name | CUSTODIAN INCORPORATION
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Dates
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Enumeration Date | 06/03/2008
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Last Update Date | 10/02/2008
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Provider Practice Location Address
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Address Line | 1891 N GAFFEY STREET SUITE L
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City | SAN PEDRO
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State | CA
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Zip | 90731
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Country | US
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Telephone | 310-833-1190
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Fax | 310-833-1196
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Provider Business Mailing Address
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Address Line | 1891 N GAFFEY STREET SUITE L
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City | SAN PEDRO
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State | CA
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Zip | 90731
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Country | US
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Telephone | 310-833-1190
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Fax | 310-833-1196
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. AKINOLA KODJO SAGOE
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Credential |
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Telephone | 310-833-1190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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