Provider Demographics
NPI:1194998765
Name:HERITAGE MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:HERITAGE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ABERA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEBRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-678-5886
Mailing Address - Street 1:1210 S LA BREA AVE STE I
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-3891
Mailing Address - Country:US
Mailing Address - Phone:310-256-4870
Mailing Address - Fax:310-673-1971
Practice Address - Street 1:1210 S LA BREA AVE STE I
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-3891
Practice Address - Country:US
Practice Address - Phone:310-256-4870
Practice Address - Fax:310-673-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48597332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies