Provider Demographics
NPI:1003861329
Name:EXPRESS MEDICAL SUPPLY
Entity Type:Organization
Organization Name:EXPRESS MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:MAGLONCIO
Authorized Official - Last Name:DEOCAMPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-423-2600
Mailing Address - Street 1:1254 LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1431
Mailing Address - Country:US
Mailing Address - Phone:619-423-2600
Mailing Address - Fax:619-423-2681
Practice Address - Street 1:639 MARSAT CT
Practice Address - Street 2:SUITE B
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-4678
Practice Address - Country:US
Practice Address - Phone:619-423-2600
Practice Address - Fax:619-423-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49252332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5724180001Medicare NSC