Provider Demographics
NPI:1720306889
Name:OZOMOR MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:OZOMOR MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:MOMATE
Authorized Official - Last Name:BIABENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-629-6845
Mailing Address - Street 1:4481 W. RENO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118
Mailing Address - Country:US
Mailing Address - Phone:702-629-6845
Mailing Address - Fax:702-629-5054
Practice Address - Street 1:4481 W. RENO AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118
Practice Address - Country:US
Practice Address - Phone:702-629-6845
Practice Address - Fax:702-629-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BX2000X
NV332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1720306889Medicaid
NV6466110001Medicare UPIN
NV1720306889Medicaid