Provider Demographics
NPI:1053479956
Name:PAK MEDICAL, INC.
Entity Type:Organization
Organization Name:PAK MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-222-6678
Mailing Address - Street 1:PO BOX 1042
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-1042
Mailing Address - Country:US
Mailing Address - Phone:770-222-6678
Mailing Address - Fax:770-222-6680
Practice Address - Street 1:5745 WENDY BAGWELL PKWY STE 32
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2885
Practice Address - Country:US
Practice Address - Phone:770-222-6678
Practice Address - Fax:770-222-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5803740001Medicare NSC