Provider Demographics
NPI:1619084720
Name:LORD'S MEDICAL SUPPLY
Entity type:Organization
Organization Name:LORD'S MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:O. TEMITOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANIFOWOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-324-0516
Mailing Address - Street 1:1552 W 139TH STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2642
Mailing Address - Country:US
Mailing Address - Phone:310-324-0516
Mailing Address - Fax:310-324-0518
Practice Address - Street 1:1552 W 139TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2642
Practice Address - Country:US
Practice Address - Phone:310-324-0516
Practice Address - Fax:310-324-0518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103477332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03219FMedicaid
CADME03219FMedicaid