MEDICARE: WANNAPORN MULLAN

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ06748Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1861500787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WANNAPORN MULLAN

Provider Business Mailing Address
First Line	:	155 SOUTH 5TH STREET
Second Line	:	SUITE A
City	:	COALINGA
State	:	CA
Zip	:	93210-1903
Country	:	US
Telephone Number	:	559-935-9350
Fax Number	:	559-935-2329

Provider Business Practice Location Address
First Line	:	155 SOUTH 5TH STREET
Second Line	:	SUITE A
City	:	COALINGA
State	:	CA
Zip	:	93210-1903
Country	:	US
Telephone Number	:	559-935-9350
Fax Number	:	559-935-2329

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. WANNAPORN MULLAN
Credential	:
Telephone Number	:	559-935-9350

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	06/23/2008

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