Provider Demographics
NPI:1881825008
Name:MISSION MEDICAL SUPPLY
Entity Type:Organization
Organization Name:MISSION MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-229-9597
Mailing Address - Street 1:4444 EL CAJON BLVD
Mailing Address - Street 2:03
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4312
Mailing Address - Country:US
Mailing Address - Phone:619-229-9597
Mailing Address - Fax:619-229-9594
Practice Address - Street 1:4444 EL CAJON BLVD
Practice Address - Street 2:03
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4312
Practice Address - Country:US
Practice Address - Phone:619-229-9597
Practice Address - Fax:619-229-9594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200901610039332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6343850001Medicare NSC