=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437343936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEMONGO MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 06/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N LA BREA AVE STE 601
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-672-8782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N LA BREA AVE STE 601
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-672-8782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ERIC LEMONGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-672-8782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 47429
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------