=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902103286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMD MEDICAL SUPPLY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2011
-----------------------------------------------------
Last Update Date | 11/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3108 ARDEN WAY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-485-2500
-----------------------------------------------------
Fax | 916-515-9191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3108 ARDEN WAY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-485-2500
-----------------------------------------------------
Fax | 916-515-9191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DMITRIY MARKIV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-485-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 348977
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------