Provider Demographics
NPI:1710049747
Name:K & K MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:K & K MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHITTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-356-4888
Mailing Address - Street 1:17410 FOOTHILL BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3651
Mailing Address - Country:US
Mailing Address - Phone:909-356-4888
Mailing Address - Fax:909-356-4920
Practice Address - Street 1:17410 FOOTHILL BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3651
Practice Address - Country:US
Practice Address - Phone:909-356-4888
Practice Address - Fax:909-356-4920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5954070001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5954070001Medicare NSC