Provider Demographics
NPI:1295882058
Name:ADVANCE MEDICAL SUPPLY
Entity type:Organization
Organization Name:ADVANCE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-653-9710
Mailing Address - Street 1:22810 ALESSANDRO BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-8549
Mailing Address - Country:US
Mailing Address - Phone:951-653-9710
Mailing Address - Fax:951-653-9719
Practice Address - Street 1:22810 ALESSANDRO BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8549
Practice Address - Country:US
Practice Address - Phone:951-653-9710
Practice Address - Fax:951-653-9719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17439332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment