Provider Demographics
NPI:1578635066
Name:L.A. MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:L.A. MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-599-9140
Mailing Address - Street 1:1621 S HIGHWAY 421 STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-7514
Mailing Address - Country:US
Mailing Address - Phone:606-599-9140
Mailing Address - Fax:606-598-0471
Practice Address - Street 1:1621 S HIGHWAY 421
Practice Address - Street 2:STE 2
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962
Practice Address - Country:US
Practice Address - Phone:606-599-9140
Practice Address - Fax:606-598-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000001181580OtherCHA PROVIDER NUMBER
KY7100202840Medicaid
KY000000069793OtherANTHEM PROVIDER NUMBER
KY45002821Medicaid
KY1196660001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER