Provider Demographics
NPI:1760507248
Name:CLEMENT ETINAYAGOMWAN AGHEDO
Entity Type:Organization
Organization Name:CLEMENT ETINAYAGOMWAN AGHEDO
Other - Org Name:ACE MEDICAL EQUIPMENT SUPPLY COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:ETINAYAGOMWAN
Authorized Official - Last Name:AGHEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-882-2640
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-0129
Mailing Address - Country:US
Mailing Address - Phone:909-882-2640
Mailing Address - Fax:909-882-2648
Practice Address - Street 1:248 E HIGHLAND AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3703
Practice Address - Country:US
Practice Address - Phone:909-882-2640
Practice Address - Fax:909-882-2648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5907100001Medicare NSC