Provider Demographics
NPI:1154312148
Name:JERRY IKE
Entity Type:Organization
Organization Name:JERRY IKE
Other - Org Name:KENLINK MEDICAL EQUIPMENT & SUPPLIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:IKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-262-7752
Mailing Address - Street 1:2306 OAK LN., STE 16
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051
Mailing Address - Country:US
Mailing Address - Phone:972-262-7752
Mailing Address - Fax:972-237-0430
Practice Address - Street 1:2306 OAK LN.
Practice Address - Street 2:STE 16
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051
Practice Address - Country:US
Practice Address - Phone:972-262-7752
Practice Address - Fax:972-237-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0071940332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI 170054401Medicaid
TXTPI 170054402Medicaid
TX=========OtherEIN
TXTPI 170054401Medicaid