Provider Demographics
NPI:1043304850
Name:KMAC, INC
Entity Type:Organization
Organization Name:KMAC, INC
Other - Org Name:GUARDIAN HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-469-4275
Mailing Address - Street 1:13737 NOEL RD STE 1300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:361-758-9336
Mailing Address - Fax:214-491-4907
Practice Address - Street 1:4444 CORONA DR STE 211
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4321
Practice Address - Country:US
Practice Address - Phone:361-758-9336
Practice Address - Fax:361-758-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX679129251E00000X
TX007780251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1511479-01Medicaid
TX151147901Medicaid
TX1511479-01Medicaid
TX1511479-01Medicaid