Provider Demographics
NPI:1144245069
Name:SPECTRUM MEDICAL AND EQUIPMENT SUPPLY
Entity Type:Organization
Organization Name:SPECTRUM MEDICAL AND EQUIPMENT SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:OKPALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-886-2263
Mailing Address - Street 1:2601 DEL ROSA AVE
Mailing Address - Street 2:B240-SUITE 104
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4412
Mailing Address - Country:US
Mailing Address - Phone:909-380-5025
Mailing Address - Fax:909-886-2263
Practice Address - Street 1:2601 DEL ROSA AVE
Practice Address - Street 2:B240-SUITE 104
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4412
Practice Address - Country:US
Practice Address - Phone:909-380-5025
Practice Address - Fax:909-886-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103779332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5230410001Medicare NSC