Provider Demographics
NPI:1598376790
Name:SUPERCARE DEPOT INC
Entity Type:Organization
Organization Name:SUPERCARE DEPOT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KHALILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-422-1720
Mailing Address - Street 1:11901 SANTA MONICA BLVD STE 470
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2767
Mailing Address - Country:US
Mailing Address - Phone:310-422-1720
Mailing Address - Fax:
Practice Address - Street 1:11901 SANTA MONICA BLVD STE 470
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2767
Practice Address - Country:US
Practice Address - Phone:310-422-1720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies