Provider Demographics
NPI:1407183528
Name:INGENIUS3 LLC
Entity Type:Organization
Organization Name:INGENIUS3 LLC
Other - Org Name:I-3 MEDICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:KWAW
Authorized Official - Last Name:WAGYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-294-9017
Mailing Address - Street 1:18119 PRAIRIE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-3740
Mailing Address - Country:US
Mailing Address - Phone:310-294-9017
Mailing Address - Fax:310-844-7712
Practice Address - Street 1:18119 PRAIRIE AVE STE 104
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-3740
Practice Address - Country:US
Practice Address - Phone:310-294-9017
Practice Address - Fax:310-844-7712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52418332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
6581310001Medicare NSC