Provider Demographics
NPI:1235235391
Name:ORTHOPAEDIC MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:ORTHOPAEDIC MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DEBENCE
Authorized Official - Suffix:
Authorized Official - Credentials:OTC
Authorized Official - Phone:951-549-9696
Mailing Address - Street 1:770 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 1H
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3120
Mailing Address - Country:US
Mailing Address - Phone:951-549-9696
Mailing Address - Fax:951-808-9952
Practice Address - Street 1:770 MAGNOLIA AVE
Practice Address - Street 2:SUITE 1H
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3120
Practice Address - Country:US
Practice Address - Phone:951-549-9696
Practice Address - Fax:951-808-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44124332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5665410001Medicare ID - Type Unspecified