=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396988507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALFA MEDICAL EQUIPMENT DEPOT & SUPPORT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2009
-----------------------------------------------------
Last Update Date | 04/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2521 W SLAUSON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90043-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-293-3983
-----------------------------------------------------
Fax | 323-293-3965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2521 W SLAUSON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90043-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-293-3983
-----------------------------------------------------
Fax | 323-293-3965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GRACE EBENUWA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 323-293-3983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 49545
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------