Provider Demographics
NPI:1295198984
Name:CANOGA MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:CANOGA MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-793-9763
Mailing Address - Street 1:310 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6218
Mailing Address - Country:US
Mailing Address - Phone:360-504-3807
Mailing Address - Fax:
Practice Address - Street 1:20944 SHERMAN WAY STE 111
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3628
Practice Address - Country:US
Practice Address - Phone:818-330-1402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies