=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992945760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S&S MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2009
-----------------------------------------------------
Last Update Date | 09/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4940 VIA CORONADO
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-6952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-600-1922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4940 VIA CORONADO
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-6952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-600-1922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JESSE WADE SPRADLING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-600-1922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 200918575
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------