Provider Demographics
NPI:1821278995
Name:IVY MEDICAL SUPPLY
Entity Type:Organization
Organization Name:IVY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:CHINWE
Authorized Official - Last Name:CHIDUEME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-484-9446
Mailing Address - Street 1:1304 S MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5118
Mailing Address - Country:US
Mailing Address - Phone:714-484-9446
Mailing Address - Fax:714-748-4157
Practice Address - Street 1:1304 S MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5118
Practice Address - Country:US
Practice Address - Phone:714-484-9446
Practice Address - Fax:714-748-4157
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY MEDICAL SUPPLY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103722332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4504180001Medicare NSC