Provider Demographics
NPI:1154369049
Name:ALLIED MEDICAL SUPPLY, INC
Entity type:Organization
Organization Name:ALLIED MEDICAL SUPPLY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LOS RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:RFO
Authorized Official - Phone:714-935-9200
Mailing Address - Street 1:170 EL CAMINO REAL STE 101
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3658
Mailing Address - Country:US
Mailing Address - Phone:714-617-4622
Mailing Address - Fax:714-617-4176
Practice Address - Street 1:170 EL CAMINO REAL STE 101
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3658
Practice Address - Country:US
Practice Address - Phone:714-617-4622
Practice Address - Fax:714-617-4176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50074332B00000X
332BC3200X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1154369049Medicaid
CA6079500001Medicare NSC