Provider Demographics
NPI:1114212446
Name:KIST MEDICAL LLC
Entity Type:Organization
Organization Name:KIST MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:TWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-233-0075
Mailing Address - Street 1:6 INVERRAY CT
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8783
Mailing Address - Country:US
Mailing Address - Phone:386-233-0075
Mailing Address - Fax:
Practice Address - Street 1:1029 S NOVA RD
Practice Address - Street 2:UNIT D
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9021
Practice Address - Country:US
Practice Address - Phone:386-233-0075
Practice Address - Fax:386-492-4749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies