Provider Demographics
NPI:1285783712
Name:MEDLIFE MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:MEDLIFE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VALENTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:POPERECHNAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-708-9444
Mailing Address - Street 1:9555 OWENSMOUTH AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-8000
Mailing Address - Country:US
Mailing Address - Phone:818-708-9444
Mailing Address - Fax:
Practice Address - Street 1:9555 OWENSMOUTH AVE STE 9
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-8000
Practice Address - Country:US
Practice Address - Phone:818-708-9444
Practice Address - Fax:888-981-8865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102667332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02282FMedicaid
CA1117070001Medicare ID - Type Unspecified