MEDICARE: BRILLIANT CARE MEDICAL SUPPLY

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	103134	CA

General Provider Information

NPI Number	:	1104923382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRILLIANT CARE MEDICAL SUPPLY

Provider Business Mailing Address
First Line	:	1680 VINE ST
Second Line	:	220
City	:	HOLLYWOOD
State	:	CA
Zip	:	90028-8804
Country	:	US
Telephone Number	:	323-466-0077
Fax Number	:	323-466-7722

Provider Business Practice Location Address
First Line	:	1680 VINE ST
Second Line	:	220
City	:	HOLLYWOOD
State	:	CA
Zip	:	90028-8804
Country	:	US
Telephone Number	:	323-466-0077
Fax Number	:	323-466-7722

Authorized Official
Title or Position	:	OWNER
Name	:	LOOKMAN L KING
Credential	:
Telephone Number	:	323-466-0077

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	12/03/2007

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