Provider Demographics
NPI:1790714566
Name:IDIMO MEDICAL SUPPLY
Entity Type:Organization
Organization Name:IDIMO MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:IDEM
Authorized Official - Last Name:ETUKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-639-1400
Mailing Address - Street 1:151 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3162
Mailing Address - Country:US
Mailing Address - Phone:651-639-1400
Mailing Address - Fax:651-639-1401
Practice Address - Street 1:151 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-3162
Practice Address - Country:US
Practice Address - Phone:651-639-1400
Practice Address - Fax:651-639-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4651550001Medicare ID - Type Unspecified