Provider Demographics
NPI:1497848543
Name:NIZHONI MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:NIZHONI MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:DAKAI
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:505-863-9199
Mailing Address - Street 1:1303 METRO DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4862
Mailing Address - Country:US
Mailing Address - Phone:505-863-9199
Mailing Address - Fax:505-863-9219
Practice Address - Street 1:1303 METRO AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5376
Practice Address - Country:US
Practice Address - Phone:505-863-9199
Practice Address - Fax:505-863-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN123894OtherINTERGRATED HEALTH
NM35488557Medicaid
AZ094395OtherAHCCCS PROVIDER NUMBER
NM5690390001Medicare ID - Type UnspecifiedPROVIDER NUMBER