Provider Demographics
NPI:1629261870
Name:ODYSSEY MEDICAL SUPPLY
Entity Type:Organization
Organization Name:ODYSSEY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTA
Authorized Official - Middle Name:O
Authorized Official - Last Name:AWANYAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-676-2142
Mailing Address - Street 1:14623 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1581
Mailing Address - Country:US
Mailing Address - Phone:310-676-2142
Mailing Address - Fax:310-676-2143
Practice Address - Street 1:14623 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1581
Practice Address - Country:US
Practice Address - Phone:310-676-2142
Practice Address - Fax:310-676-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102144332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4068940001Medicare NSC