Provider Demographics
NPI:1548410251
Name:ADIMORAH, REGINALD N
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:N
Last Name:ADIMORAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 W 54TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2612
Mailing Address - Country:US
Mailing Address - Phone:323-292-2700
Mailing Address - Fax:310-219-0653
Practice Address - Street 1:2507 W 54TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2612
Practice Address - Country:US
Practice Address - Phone:323-292-2700
Practice Address - Fax:310-219-0653
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46549332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5974000001Medicare NSC