Provider Demographics
NPI:1942087192
Name:ADVANCE SUPPLY LLC
Entity Type:Organization
Organization Name:ADVANCE SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KONSTANTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-662-2210
Mailing Address - Street 1:990 SPRUCE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-4566
Mailing Address - Country:US
Mailing Address - Phone:917-662-2210
Mailing Address - Fax:
Practice Address - Street 1:990 SPRUCE ST STE 202
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4566
Practice Address - Country:US
Practice Address - Phone:917-662-2210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies