Provider Demographics
NPI:1710164595
Name:ST. JOHN'S DME INC.
Entity Type:Organization
Organization Name:ST. JOHN'S DME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BASSEY
Authorized Official - Last Name:IKPEME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-672-6657
Mailing Address - Street 1:305 E HILLCREST BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-2405
Mailing Address - Country:US
Mailing Address - Phone:310-672-6657
Mailing Address - Fax:310-671-2870
Practice Address - Street 1:305 E HILLCREST BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-2405
Practice Address - Country:US
Practice Address - Phone:310-672-6657
Practice Address - Fax:310-671-2870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103708332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5403020001Medicare NSC