Provider Demographics
NPI:1467873646
Name:WATERGREEN MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:WATERGREEN MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:TREJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-651-8059
Mailing Address - Street 1:2875 DOUGLAS WAY
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-6066
Mailing Address - Country:US
Mailing Address - Phone:714-651-8059
Mailing Address - Fax:
Practice Address - Street 1:2875 DOUGLAS WAY
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-6066
Practice Address - Country:US
Practice Address - Phone:714-651-8059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-14
Last Update Date:2013-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient