MEDICARE: GOZIE TONY EZEMONYE

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	101671	CA

General Provider Information

NPI Number	:	1063582575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOZIE TONY EZEMONYE

Provider Business Mailing Address
First Line	:	PO BOX 86
Second Line	:
City	:	HAWTHORNE
State	:	CA
Zip	:	90251-0086
Country	:	US
Telephone Number	:	310-676-0576
Fax Number	:	310-676-9109

Provider Business Practice Location Address
First Line	:	4448 W.EL SEGUNDO BL.
Second Line	:
City	:	HAWTHORNE
State	:	CA
Zip	:	90250-4421
Country	:	US
Telephone Number	:	310-676-0576
Fax Number	:	310-676-9109

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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