Provider Demographics
NPI:1477669042
Name:CLARENCE M. HYSHAW/MID-CITY ORTHO & NEURO SUPPLY
Entity Type:Organization
Organization Name:CLARENCE M. HYSHAW/MID-CITY ORTHO & NEURO SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENON
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-669-9806
Mailing Address - Street 1:3622 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2607
Mailing Address - Country:US
Mailing Address - Phone:310-669-9806
Mailing Address - Fax:310-669-9804
Practice Address - Street 1:3622 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2607
Practice Address - Country:US
Practice Address - Phone:310-669-9806
Practice Address - Fax:310-669-9804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2531332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5172230001Medicare NSC