MEDICARE: MILLBRAE MEDICAL SUPPLY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	DME00543F	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DME00543F	OTHER	CA	MEDI-CAL PROVIDER

General Provider Information

NPI Number	:	1013907468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLBRAE MEDICAL SUPPLY, INC

Provider Business Mailing Address
First Line	:	425 OLD COUNTY RD STE C
Second Line	:
City	:	BELMONT
State	:	CA
Zip	:	94002-2500
Country	:	US
Telephone Number	:	650-593-2188
Fax Number	:	650-593-2044

Provider Business Practice Location Address
First Line	:	425 OLD COUNTY RD STE C
Second Line	:
City	:	BELMONT
State	:	CA
Zip	:	94002-2500
Country	:	US
Telephone Number	:	650-593-2188
Fax Number	:	650-593-2044

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. OLIVER W FRIEDAUER
Credential	:
Telephone Number	:	650-593-2188

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	11/19/2013

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