=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619993029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE MEDICAL EQUIPMENT & SUPPLIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1704 W MANCHESTER AVE SUITE 204D
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-758-7550
-----------------------------------------------------
Fax | 323-758-5550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 W MANCHESTER AVE SUITE 204D
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-758-7550
-----------------------------------------------------
Fax | 323-758-5550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | MR. ALULA BEKELE BERHANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-714-9667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 103338
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------