Provider Demographics
NPI:1407945249
Name:PROCARE MEDICAL SUPPLY AND DISTRIBUTION INC
Entity Type:Organization
Organization Name:PROCARE MEDICAL SUPPLY AND DISTRIBUTION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ADEDAPO
Authorized Official - Last Name:ADESIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-748-9904
Mailing Address - Street 1:1910 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3624
Mailing Address - Country:US
Mailing Address - Phone:310-515-0507
Mailing Address - Fax:310-515-1668
Practice Address - Street 1:1910 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3624
Practice Address - Country:US
Practice Address - Phone:310-515-0507
Practice Address - Fax:310-515-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5384060001Medicare ID - Type UnspecifiedPROVIDER NUMBER