Provider Demographics
NPI:1629406756
Name:LA BASE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:LA BASE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CALLISTUS
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEAKOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-518-9360
Mailing Address - Street 1:7770 HIGHWAY 6 S # 367
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-3319
Mailing Address - Country:US
Mailing Address - Phone:713-518-9360
Mailing Address - Fax:281-302-6897
Practice Address - Street 1:9302 EAGLEWOOD GLEN TRL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-6285
Practice Address - Country:US
Practice Address - Phone:713-518-9360
Practice Address - Fax:281-302-6897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000491332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies