Provider Demographics
NPI:1417041112
Name:ANGELES VISTA MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:ANGELES VISTA MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE-PROPRIETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARKSON
Authorized Official - Middle Name:BOLA
Authorized Official - Last Name:ALABI
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:562-699-7200
Mailing Address - Street 1:11929 LOS NIETOS ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-2527
Mailing Address - Country:US
Mailing Address - Phone:562-699-7200
Mailing Address - Fax:562-699-7210
Practice Address - Street 1:11929 LOS NIETOS ROAD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-2527
Practice Address - Country:US
Practice Address - Phone:562-699-7200
Practice Address - Fax:562-699-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADME02177F332B00000X, 332BC3200X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02177FMedicaid