Provider Demographics
NPI:1831143494
Name:LIA ST JUNIUS
Entity Type:Organization
Organization Name:LIA ST JUNIUS
Other - Org Name:MOBILITY STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. JUNIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-432-1375
Mailing Address - Street 1:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-0821
Mailing Address - Country:US
Mailing Address - Phone:888-432-1375
Mailing Address - Fax:713-432-1395
Practice Address - Street 1:505 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2830
Practice Address - Country:US
Practice Address - Phone:562-989-6308
Practice Address - Fax:562-989-6306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0086788332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176699002Medicaid
CA5148270001Medicare NSC