Provider Demographics
NPI:1558746198
Name:KANAWHA MEDICAL SUPPLY
Entity Type:Organization
Organization Name:KANAWHA MEDICAL SUPPLY
Other - Org Name:KANAWHA PERSONAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECT OWNER/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:PERGERSONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-330-5743
Mailing Address - Street 1:7009 FOREST HILL AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-1607
Mailing Address - Country:US
Mailing Address - Phone:804-330-5743
Mailing Address - Fax:804-330-7149
Practice Address - Street 1:7009 FOREST HILL AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1607
Practice Address - Country:US
Practice Address - Phone:804-330-5743
Practice Address - Fax:804-330-7149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KANAWHA MEDICAL SUPPLY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0087009400Medicaid
VA0102181440Medicaid
VA0087720295Medicaid
VA0102181952Medicaid
VA0102164867Medicaid