=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952701534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ULTRA MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2014
-----------------------------------------------------
Last Update Date | 09/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2022 FILMORE AVE #26
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16506-2978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-796-7555
-----------------------------------------------------
Fax | 516-566-2395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2022 FILMORE AVE #26
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16506-2978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-796-7555
-----------------------------------------------------
Fax | 516-566-2395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | EZRIEL UNGAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-796-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1466586
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------