Provider Demographics
NPI:1104091693
Name:1ST MEDICAL SUPPLY
Entity type:Organization
Organization Name:1ST MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:V
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-870-0853
Mailing Address - Street 1:2725 S JONES BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5605
Mailing Address - Country:US
Mailing Address - Phone:702-870-0853
Mailing Address - Fax:702-870-2797
Practice Address - Street 1:2725 S JONES BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5605
Practice Address - Country:US
Practice Address - Phone:702-870-0853
Practice Address - Fax:702-870-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS20592335E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVS20592OtherFACILITY ACCREDITATION
NVS20592OtherFACILITY ACCREDITATION