Provider Demographics
NPI:1891745915
Name:VANTAGE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:VANTAGE MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:MADUABUCHI
Authorized Official - Last Name:OKWARAJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-763-2234
Mailing Address - Street 1:427 N LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-2218
Mailing Address - Country:US
Mailing Address - Phone:310-763-2234
Mailing Address - Fax:310-763-2058
Practice Address - Street 1:427 N LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-2218
Practice Address - Country:US
Practice Address - Phone:310-763-2234
Practice Address - Fax:310-763-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332BC3200X
CA103756332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8577638Medicaid
5717400001Medicare NSC
CA5717400001Medicare NSC