Provider Demographics
NPI:1336420744
Name:AMIRA MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:AMIRA MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:IGELEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-547-5991
Mailing Address - Street 1:3650 E FLAMINGO RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4934
Mailing Address - Country:US
Mailing Address - Phone:702-547-5991
Mailing Address - Fax:702-547-5992
Practice Address - Street 1:3650 E FLAMINGO RD
Practice Address - Street 2:SUITE 4
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4934
Practice Address - Country:US
Practice Address - Phone:702-547-5991
Practice Address - Fax:702-547-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20111500986332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6684680001OtherPROVIDER TRANSACTION ACCESS NUMBER