Provider Demographics
NPI:1619072873
Name:EASY LIFE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:EASY LIFE MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHATKHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-986-4294
Mailing Address - Street 1:3625 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6854
Mailing Address - Country:US
Mailing Address - Phone:954-986-4294
Mailing Address - Fax:
Practice Address - Street 1:3625 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6854
Practice Address - Country:US
Practice Address - Phone:954-986-4294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5783840001Medicare NSC