Provider Demographics
NPI:1992876502
Name:MEDICAL STORE
Entity type:Organization
Organization Name:MEDICAL STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:KREINDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-722-1128
Mailing Address - Street 1:333 E 17TH ST
Mailing Address - Street 2:SUITE 23
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3220
Mailing Address - Country:US
Mailing Address - Phone:949-722-1128
Mailing Address - Fax:949-722-1315
Practice Address - Street 1:333 E 17TH ST
Practice Address - Street 2:SUITE 23
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3220
Practice Address - Country:US
Practice Address - Phone:949-722-1128
Practice Address - Fax:949-722-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102786332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4600070001Medicare ID - Type UnspecifiedNON ASSIGNED