Provider Demographics
NPI:1336161272
Name:ATLANTIS MEDICAL EQUIPMENTS & SUPPLY COMPANY, LLC
Entity Type:Organization
Organization Name:ATLANTIS MEDICAL EQUIPMENTS & SUPPLY COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHINWENDU
Authorized Official - Middle Name:IKE
Authorized Official - Last Name:MBANUGO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-266-0575
Mailing Address - Street 1:30900 FORD RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-1892
Mailing Address - Country:US
Mailing Address - Phone:734-266-0575
Mailing Address - Fax:734-266-0971
Practice Address - Street 1:30900 FORD RD
Practice Address - Street 2:SUITE F
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-1892
Practice Address - Country:US
Practice Address - Phone:734-266-0575
Practice Address - Fax:734-266-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4862749332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4862749Medicaid
MI4862749Medicaid