=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649583477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AIDMED INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2010
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 N RICHARDSON AVE
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-4828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-895-8303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11490 BURBANK BLVD STE 1D
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91601-2389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-895-8303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JERRY L GRAY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 877-895-8303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 32D0537453
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------