=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710305461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 3RD ST MEDICAL SUPPLY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2014
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1261 S LYON ST SUITE 05
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-988-6585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1261 S LYON ST SUITE 05
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-988-6585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NOHA M ABDELLATIF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-988-6585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------