MEDICARE: MR. MEDUOYE O. OMOYELE

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	332B00000X	CA

General Provider Information

NPI Number	:	1255446068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MEDUOYE O. OMOYELE

Provider Business Mailing Address
First Line	:	1400 S HAYWORTH AVE STE 216
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4814
Country	:	US
Telephone Number	:	323-933-9105
Fax Number	:	323-933-9384

Provider Business Practice Location Address
First Line	:	1400 S HAYWORTH AVE STE 216
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4814
Country	:	US
Telephone Number	:	323-933-9105
Fax Number	:	323-933-9384

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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