Provider Demographics
NPI:1639361009
Name:LADERA MEDICAL SUPPLY,INC
Entity Type:Organization
Organization Name:LADERA MEDICAL SUPPLY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-299-8334
Mailing Address - Street 1:4720 W SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1206
Mailing Address - Country:US
Mailing Address - Phone:323-299-8334
Mailing Address - Fax:323-299-8384
Practice Address - Street 1:4720 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1206
Practice Address - Country:US
Practice Address - Phone:323-299-8334
Practice Address - Fax:323-299-8384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
6022410001Medicare NSC