Provider Demographics
NPI:1033154414
Name:AMANDA CARE MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:AMANDA CARE MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:TRENIESE
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-949-7911
Mailing Address - Street 1:1113 ALTA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2803
Mailing Address - Country:US
Mailing Address - Phone:909-949-7911
Mailing Address - Fax:909-949-3061
Practice Address - Street 1:1113 ALTA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-2803
Practice Address - Country:US
Practice Address - Phone:909-949-7911
Practice Address - Fax:909-949-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5301650001Medicare ID - Type Unspecified