Provider Demographics
NPI:1316251937
Name:ELK GROVE MEDICAL SUPPLIES, INC
Entity type:Organization
Organization Name:ELK GROVE MEDICAL SUPPLIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-686-9595
Mailing Address - Street 1:8949 ELK GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1942
Mailing Address - Country:US
Mailing Address - Phone:916-686-9595
Mailing Address - Fax:916-686-9596
Practice Address - Street 1:8949 ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1942
Practice Address - Country:US
Practice Address - Phone:916-686-9595
Practice Address - Fax:916-686-9596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52828332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies