Provider Demographics
NPI:1285617761
Name:LIFECARE MEDICAL SUPPLIES INC
Entity type:Organization
Organization Name:LIFECARE MEDICAL SUPPLIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLETUS
Authorized Official - Middle Name:ONYE
Authorized Official - Last Name:AMADI
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:702-696-1527
Mailing Address - Street 1:6415 S FORT APACHE RD STE 170
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-6747
Mailing Address - Country:US
Mailing Address - Phone:702-696-1527
Mailing Address - Fax:702-696-1591
Practice Address - Street 1:6415 S FORT APACHE RD STE 170
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-6747
Practice Address - Country:US
Practice Address - Phone:702-696-1527
Practice Address - Fax:702-696-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV005802700332B00000X
NV003302700332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003302700Medicaid
NV003302700Medicaid