MEDICARE: GUSTINO MEDICAL SUPPLY CO.

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	102504	CA

General Provider Information

NPI Number	:	1598756900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUSTINO MEDICAL SUPPLY CO.

Provider Business Mailing Address
First Line	:	13998 CRENSHAW BLVD
Second Line	:	P.O. BOX 1588
City	:	GARDENA
State	:	CA
Zip	:	90249-2714
Country	:	US
Telephone Number	:	310-523-2123
Fax Number	:	310-523-2192

Provider Business Practice Location Address
First Line	:	13998 CRENSHAW BLVD
Second Line	:
City	:	GARDENA
State	:	CA
Zip	:	90249-2714
Country	:	US
Telephone Number	:	310-523-2123
Fax Number	:	310-523-2192

Authorized Official
Title or Position	:	OWNER
Name	:	MR. AUGUSTINE OKON UWAH
Credential	:
Telephone Number	:	310-523-2123

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	08/12/2008

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