Provider Demographics
NPI:1376820555
Name:INNOVATIVE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:INNOVATIVE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VIDAL
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:IRABOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-204-5623
Mailing Address - Street 1:8306 FLATLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3506
Mailing Address - Country:US
Mailing Address - Phone:347-562-3046
Mailing Address - Fax:347-713-5334
Practice Address - Street 1:8306 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3506
Practice Address - Country:US
Practice Address - Phone:347-562-3046
Practice Address - Fax:347-713-5334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies