Provider Demographics
NPI:1194900860
Name:AMANDA CARE MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:AMANDA CARE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-949-7911
Mailing Address - Street 1:8200 HAVEN AVE
Mailing Address - Street 2:2110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8165
Mailing Address - Country:US
Mailing Address - Phone:909-949-7911
Mailing Address - Fax:
Practice Address - Street 1:8200 HAVEN AVE
Practice Address - Street 2:2110
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-8165
Practice Address - Country:US
Practice Address - Phone:909-949-7911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103790332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5779020001Medicare NSC