Provider Demographics
NPI:1619191137
Name:KENNESAW MEDICAL SUPPLY
Entity Type:Organization
Organization Name:KENNESAW MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIOVANNA
Authorized Official - Middle Name:TAMARA
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-974-6797
Mailing Address - Street 1:3600 CHEROKEE ST NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2027
Mailing Address - Country:US
Mailing Address - Phone:770-425-8709
Mailing Address - Fax:770-425-8744
Practice Address - Street 1:3600 CHEROKEE ST NW
Practice Address - Street 2:SUITE 120
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2027
Practice Address - Country:US
Practice Address - Phone:770-425-8709
Practice Address - Fax:770-425-8744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies