Provider Demographics
NPI:1154482073
Name:KEVIN ROSS SUPPLY CORP
Entity Type:Organization
Organization Name:KEVIN ROSS SUPPLY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ONEIDA
Authorized Official - Middle Name:DIAZ
Authorized Official - Last Name:LICEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-232-2006
Mailing Address - Street 1:15715 S DIXIE HWY
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1800
Mailing Address - Country:US
Mailing Address - Phone:305-232-2006
Mailing Address - Fax:
Practice Address - Street 1:15715 S DIXIE HWY
Practice Address - Street 2:SUITE 410
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1800
Practice Address - Country:US
Practice Address - Phone:305-232-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies