=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750387114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAM MEDICAL SUPPLY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 E DESERT INN RD STE 2
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89109-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-369-0510
-----------------------------------------------------
Fax | 702-369-9846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 E DESERT INN RD STE 2
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89109-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-369-0510
-----------------------------------------------------
Fax | 702-369-9846
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. ANA A. BEAVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-369-0510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2000087.424
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------