Provider Demographics
NPI:1609887108
Name:KABAFUSION WY, LLC
Entity Type:Organization
Organization Name:KABAFUSION WY, LLC
Other - Org Name:KABAFUSION WY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SOHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-435-3020
Mailing Address - Street 1:80 HAYDEN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-7962
Mailing Address - Country:US
Mailing Address - Phone:800-435-3020
Mailing Address - Fax:
Practice Address - Street 1:1030 N POPLAR ST
Practice Address - Street 2:STE A
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1378
Practice Address - Country:US
Practice Address - Phone:307-266-2273
Practice Address - Fax:307-266-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BP3500X
WYR100243336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0294030874Medicare NSC