Provider Demographics
NPI:1023007762
Name:KERN VALLEY MEDICAL SUPPLY
Entity Type:Organization
Organization Name:KERN VALLEY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-379-8111
Mailing Address - Street 1:5213 LAKE ISABELLA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9642
Mailing Address - Country:US
Mailing Address - Phone:760-379-8111
Mailing Address - Fax:760-379-1411
Practice Address - Street 1:5213 LAKE ISABELLA BLVD
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9642
Practice Address - Country:US
Practice Address - Phone:760-379-8111
Practice Address - Fax:760-379-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME01806FMedicaid
CADME01806FMedicaid