=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356449722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-CITY MEDICAL SUPPLY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11900 S AVALON BLVD SUITE 201
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90061-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-757-8992
-----------------------------------------------------
Fax | 323-757-3634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11900 S AVALON BLVD SUITE 201
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90061-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-757-8992
-----------------------------------------------------
Fax | 323-757-3634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ASSEFA FIKRE WELDEMESKEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-757-8992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------