{
"Npi": {
"NPI": "1639106685",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "WESTERN IMPERIAL MEDICAL DISTRIBUTORS",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2930 WEST IMPERIAL HWY",
"SecondLineMailingAddress": "SUITE 200Q",
"MailingAddressCityName": "INGLEWOOD",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90303",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "323-755-0148",
"MailingAddressFaxNumber": "323-755-5555",
"FirstLinePracticeLocationAddress": "2930 W IMPERIAL HWY",
"SecondLinePracticeLocationAddress": "SUITE 200Q",
"PracticeLocationAddressCityName": "INGLEWOOD",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "90303-3143",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "323-755-0148",
"PracticeLocationAddressFaxNumber": "323-755-5555",
"EnumerationDate": "06/26/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DAMAKO",
"AuthorizedOfficialFirstName": "YAKUBU",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "323-755-0148",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332B00000X",
"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": "4270040001",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}