=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952315608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCE MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7771 UNIVERSITY AVE
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-4950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-466-9255
-----------------------------------------------------
Fax | 619-466-9254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7771 UNIVERSITY AVE
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-4950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-466-9255
-----------------------------------------------------
Fax | 619-466-9254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | P
-----------------------------------------------------
Name | AZHER A HADDAWI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-466-9255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 52149
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------