=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346451937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROCARE MEDICAL SUPPLY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 12/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1260 S SOTO ST UNIT 3
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90023-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-262-5600
-----------------------------------------------------
Fax | 323-262-5700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1260 S SOTO ST UNIT 3
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90023-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-262-5600
-----------------------------------------------------
Fax | 323-262-5700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SARGIS KHACHERIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-262-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------