Provider Demographics
NPI:1578613428
Name:SOUTH BAY MEDICAL SUPPLY
Entity Type:Organization
Organization Name:SOUTH BAY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:EJIZU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-522-4200
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90748-0663
Mailing Address - Country:US
Mailing Address - Phone:310-522-4200
Mailing Address - Fax:310-522-4244
Practice Address - Street 1:735 BROAD AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5833
Practice Address - Country:US
Practice Address - Phone:310-522-4200
Practice Address - Fax:310-522-4244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46263332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5925310001Medicare NSC