Provider Demographics
NPI:1770055477
Name:PROVISION MEDICAL SUPPLY
Entity type:Organization
Organization Name:PROVISION MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-662-3933
Mailing Address - Street 1:777 W 19TH ST STE F
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-6131
Mailing Address - Country:US
Mailing Address - Phone:949-662-3933
Mailing Address - Fax:
Practice Address - Street 1:777 W 19TH ST STE F
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-6131
Practice Address - Country:US
Practice Address - Phone:949-662-3933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies