Provider Demographics
NPI:1184024879
Name:ULTRA MEDICAL SUPPLY
Entity Type:Organization
Organization Name:ULTRA MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:EZRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:UNGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-796-7555
Mailing Address - Street 1:1331 BASELINE RD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6719
Mailing Address - Country:US
Mailing Address - Phone:718-796-7555
Mailing Address - Fax:516-566-2395
Practice Address - Street 1:1331 BASELINE RD
Practice Address - Street 2:UNIT 2
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6719
Practice Address - Country:US
Practice Address - Phone:718-796-7555
Practice Address - Fax:516-566-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21026176332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ898874Medicaid