Provider Demographics
NPI:1598756900
Name:GUSTINO MEDICAL SUPPLY CO.
Entity Type:Organization
Organization Name:GUSTINO MEDICAL SUPPLY CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:OKON
Authorized Official - Last Name:UWAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-523-2123
Mailing Address - Street 1:13998 CRENSHAW BLVD
Mailing Address - Street 2:P.O. BOX 1588
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2714
Mailing Address - Country:US
Mailing Address - Phone:310-523-2123
Mailing Address - Fax:310-523-2192
Practice Address - Street 1:13998 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2714
Practice Address - Country:US
Practice Address - Phone:310-523-2123
Practice Address - Fax:310-523-2192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102504332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1313460001Medicare ID - Type Unspecified