Provider Demographics
NPI:1336320639
Name:MED-DME SUPPLY INC
Entity Type:Organization
Organization Name:MED-DME SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORELISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-446-0700
Mailing Address - Street 1:8340 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-2849
Mailing Address - Country:US
Mailing Address - Phone:818-446-0700
Mailing Address - Fax:818-446-0064
Practice Address - Street 1:8340 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SUNLAND
Practice Address - State:CA
Practice Address - Zip Code:91040-2849
Practice Address - Country:US
Practice Address - Phone:818-446-0700
Practice Address - Fax:818-446-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5724590001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5724590001Medicare NSC