Provider Demographics
NPI:1477507671
Name:EDC MEDICAL SUPPLY INC.
Entity Type:Organization
Organization Name:EDC MEDICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:BODE
Authorized Official - Last Name:ADEMISOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-492-4884
Mailing Address - Street 1:355 E AVENIDA DE LOS ARBOLES
Mailing Address - Street 2:SUITE B
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-2973
Mailing Address - Country:US
Mailing Address - Phone:805-492-4884
Mailing Address - Fax:805-492-4877
Practice Address - Street 1:355 E AVENIDA DE LOS ARBOLES
Practice Address - Street 2:SUITE B
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-2973
Practice Address - Country:US
Practice Address - Phone:805-492-4884
Practice Address - Fax:805-492-4877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103794332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5283780001Medicare NSC