Provider Demographics
NPI:1538305198
Name:KCAMLAED MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:KCAMLAED MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-333-2498
Mailing Address - Street 1:15341 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:IL
Mailing Address - Zip Code:60426-2620
Mailing Address - Country:US
Mailing Address - Phone:708-333-2498
Mailing Address - Fax:
Practice Address - Street 1:16900 LATHROP AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-6033
Practice Address - Country:US
Practice Address - Phone:708-596-5671
Practice Address - Fax:708-596-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-31
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier