Provider Demographics
NPI:1578595641
Name:KNC MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:KNC MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OKAFOR
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:323-299-0837
Mailing Address - Street 1:4718 S MULLEN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1718
Mailing Address - Country:US
Mailing Address - Phone:323-299-0837
Mailing Address - Fax:323-299-0839
Practice Address - Street 1:3931 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2976
Practice Address - Country:US
Practice Address - Phone:323-299-0837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADME03143G332B00000X, 332BC3200X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03143GMedicaid
CADME03143GMedicaid