Provider Demographics
NPI:1629623210
Name:ELITE MEDICAL SUPPLY GROUP LLC
Entity Type:Organization
Organization Name:ELITE MEDICAL SUPPLY GROUP LLC
Other - Org Name:ELITE MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTYLEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-414-5700
Mailing Address - Street 1:1071 BRIGHTON BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5602
Mailing Address - Country:US
Mailing Address - Phone:347-414-5700
Mailing Address - Fax:347-406-6100
Practice Address - Street 1:1071 BRIGHTON BEACH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5602
Practice Address - Country:US
Practice Address - Phone:347-414-5700
Practice Address - Fax:347-406-6100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELITE MEDICAL SUPPLY GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-09
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies