Provider Demographics
NPI:1205990819
Name:ADVANCED MOBILITY MEDICAL EQUIP SUPPLY
Entity type:Organization
Organization Name:ADVANCED MOBILITY MEDICAL EQUIP SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ICHEGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-792-9357
Mailing Address - Street 1:126 SOUTH ALICE STREET
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1652
Mailing Address - Country:US
Mailing Address - Phone:334-792-9357
Mailing Address - Fax:334-792-9367
Practice Address - Street 1:126 SOUTH ALICE STREET
Practice Address - Street 2:SUITE 4
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1652
Practice Address - Country:US
Practice Address - Phone:334-792-9357
Practice Address - Fax:334-792-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935224Medicaid
AL51532500OtherBC BS
AL51532500OtherBCBS
AL51532500OtherBC BS
AL009935224Medicaid
5489720001Medicare NSC