Provider Demographics
NPI:1821208943
Name:BERNARD S GIBESON
Entity Type:Organization
Organization Name:BERNARD S GIBESON
Other - Org Name:CONQUEST MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-630-5885
Mailing Address - Street 1:1900 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3624
Mailing Address - Country:US
Mailing Address - Phone:310-630-5885
Mailing Address - Fax:310-630-0189
Practice Address - Street 1:1900 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3624
Practice Address - Country:US
Practice Address - Phone:310-630-5885
Practice Address - Fax:310-630-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1317830001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1317830001Medicare NSC